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Based on interview and record review, Facility #1, a hospital, failed to provide a sanitary environment to protect patients from cross contamination of infection through physical contact for 3 (#11, 12, 13) of 13 (#1-13) sampled patients, all of whom were discharged with wounds and/or infections and/or fractured bones. This failed practice resulted in the exposure of these 3 patients to actual harm through cross contamination of clostridium difficile (a spore-like bacteria) which is very difficult to treat, creates uncontrollable diarrhea, and was listed on Patient #11's autopsy as a contributing cause to her death. The findings are:

A. On 10/28/15 at 11:15 am during interview, the complainant, Developmentally Delayed Support Division (DDSD) Registered Nurse (RN) #1, offered the following:
Patient #11 was a 77-year-old female, admitted to Facility #1, on 06/22/15. She had fallen at her day care activity. Patient #11 had fractured her left hip and had a history of schizophrenia, a thought disorder marked by delusions, hallucinations, and disorganized behavior. During her stay at Facility #1 she acquired a respiratory infection, a urinary tract infection, and clostridium difficile (also known as c. difficile) infection in her large intestine. She also acquired a stage II (break of the skin) decubitus ulcer on her buttocks while in the facility. She was discharged back to Facility #2, a skilled nursing facility, on 07/03/15.

B. Record review indicated Patient #11 became ill on 07/27/15 while in facility #2 and was later admitted with a diagnosis of sepsis (blood or global infection) to Facility #3, a hospital. She died in Facility #3 on 08/01/15.

C. On 10/29/15 at 9:15 am during interview, DDSD RN #2 stated the following:
"[DDSD RN #1] and I were both concerned about the discharge of Patient #11 from Facility #1. We had two other patients go to Facility #1 for acute care and they came out with c. difficile infections in their bowels. Their names were [Patient #12] admitted 06/16/15, discharged 06/19/15, with a diagnosis of shunt [drain in brain] infection and [Patient #13], admitted 08/24/15 and discharged 09/23/15, diagnosis of bowel obstruction."

D. On 10/29/15 at 13:45 am during interview, Citizens for Developmentally Disabled (CDD) Registered Nurse (RN) #3 offered the following: "We [DDSD] have actually had three patients who came out of [Facility #1] with the c. difficile infection. The infections were confirmed when they were admitted to other facilities. So we are really concerned about what is going on over there."

E. Record review of the clinical record of of Patient #13 indicated that this patient was admitted to Facility #1 on 08/24/15 with a diagnosis of bowel obstruction. He received 3 bowel surgeries while there and was discharged with a diagnosis of c. difficile in his bowel.

F. On 10/28/15 at 1:30 pm during interview, the Interim Chief Nursing Executive of Facility #1 stated the following: "Our discharge packet from [Hospital #1] included wound care notes and instructions, medications for the pneumonia, urinary tract infection, and c. difficile, and other instructions including a follow-up appointment with [Patient #11's] primary care physician on 07/14/15 at 9:15 am. We reviewed these 3 charts and confirm that at least 2 [Patients #11 and 12] of the 3 patients tested positive for c. difficile before discharge."

G. Record review of the clinical records of Patients #11 and #12 confirmed they tested positive for c. difficile in their bowels.

H. Record review of the Report of Findings [for Patient #11], Office of the Medical Examiner, dated 09/06/15, indicated the cause of death was blunt hip trauma; other significant contributing conditions were clostridium difficile infection, hypertension, cardiovascular disease, diabetes mellitus; and the manner of death was accidental.