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Based on review of 1 of 5 medical records (#1), the comprehensive epidemiology report from 7/1/09 to 5/6/10, and interviews, the hospital failed to ensure the infection control officer reported accurate data to the QA/PI coordinator regarding MDROs. This was evidenced by the failure of the infection control officer to identify, analyze, and track 8 patients with an MDRO not reported to the infection control department through the computer software program. Findings:

Review of the medical record revealed on 1/26/2010 patient #1 was on a mechanical ventilator in ICU2 (step-down unit) and had a positive sputum culture with Acinetobacter, a MDRO (multidrug resistant organism). Further review of the medical record failed to reveal patient #1 was placed on contact isolation.

An interview on 5/03/2010 at 11:30 AM with S1 infection control officer revealed there was hospital wide surveillance of MDROs and she added the infection control department used a computer system with a dashboard to track all infections in the hospital. S1 stated the computer program also indicated what organism was hospital acquired (the infection developed 48 hours after admission) and when this occurred, she reviewed the clinical record and gathered information to identify any trends or concern which enabled the hospital to deploy resources should there be any trends. S1 stated last quarter (1/2010-4/1/2010) the hospital's nosocomial infection rate for patients on ventilators was 1.1 % but the percentage was calculated on the number of ventilator days during that quarter.

In an interview on 5/05/2010 at 3:35 PM, S3 RN/Director of Quality reported the data from infection control audits go to quarterly Quality Council meetings and then reported to medical staff. S3 also indicated the infection control officer (S1) and her staff received a call from lab when they have a positive culture requiring isolation and that the infection control team double checked to verify the unit was using the correct isolation cart and the correct isolation instruction card to alert visitors and staff to what personal protective equipment was needed for the different types of isolation.

Interview with S1 infection control officer on 5/6/10 at 8:25 AM revealed she looked for all patients who cultured an Acinetobacter organism from July 2009 when a new computer software was installed. S1 indicated patient #1's information regarding rhe Acinetobacter organism was not included in her report. S1 also stated in the interview that the laboratory department would have a policy for which organisms that should alert the infection control department and the alert would include Acinetobacter organisms. S1 stated at that time she did not know why the infection control department was not alerted that patient #1 had cultured an Acinetobacter organism because her department was tracking all patients with Acinetobacter if reported to her department.

S1 further stated that she just realized after reviewing patient #1's medical record with the survey team that the hospital had a problem with the lab computer software program not alerting her department of all MDRO infections. S1 indicated she could not determine how many Acinetobacter infections her department had missed because she knew the 1/26/2010 sputum culture results for patient #1's was not reported to infection control. S1 also indicated she depended on her computer software (installed and ready for use July 2009 and interfaced with the lab computer system) to alert infection control of all multidrug-resistant organisms.

In an interview on 5/06/2010 at 9:00 AM S3 Director of Quality, stated after she investigated the reason infection control did not receive an alert from lab that patient #1 had a MDRO and was not placed in contact isolation, she discovered that the lab's policy did not include reporting patients that cultured an Acinetobacter organism; therefore they did not call the infection control department or the unit nurse. She further stated the lab policy only directs the lab tech to call when VRE, MRSA, and C-diff organism were isolated.

On 5/07/10 at 1:00 PM, S1 Infection Control Officer stated after checking with SPD (sterile processing department which supplies the isolation carts) and comparing the information she received in her department, she found 8 patients were missed who cultured Acinetobacter infections (from 7/01/2009-5/06/2010). S1 indicated the 8 patients with Acinetobacter were considered multidrug resistant and not placed in contact isolation. S1 further stated her computer program failed to alert her of the positive cultures which required contact isolation to prevent the spread of the infectious organisms. S1 confirmed the infection control department totally relied on the computer system to alert her to all infections in the hospital and the system failed to do that. During the interview S1 stated the infection control data that she submitted to QA/PI was not accurate because the data did not include all patients with infectious organisms.

Based on review of the electronic medical record for patients #1 and #2, in a total sample of 5, review of nursing policies and procedures, and staff interviews, the RN (registered nurse) failed to assess the health status/condition and evaluate the care for each patient to include reviewing laboratory culture results as evidenced by patients with Acinetobacter organisms not being placed in contact isolation. Findings:

Patient #1
Review of the electronic medical record for patient #1 revealed an admission date of 12/9/09 with diagnoses that included bacterial pneumonia, urinary tract infection, malnutrition, and a form of muscular dystrophy. During the course of treatment, patient #1 required intubation, then a tracheostomy with night time ventilator support. As patient #1 improved, she was transferred to a stepdown unit, ICU2, on 1/22/10. While in ICU2, patient #1 developed a positive sputum culture with Acinetobacter baumannii- a multidrug resistant organism (MDRO) on 1/24/10. Patient #1 became febrile and required a transfer to SICU on 1/29/10. Further review of the electronic medical record revealed patient #1 was not placed in contact isolation for the MDRO when the lab result was received as per hospital policy.

On 5/07/2010 at 11:00 AM, interview with S5RN revealed she was patient #1's nurse on the day shift (7AM-7PM) when the patient was first admitted to ICU 2 (step down unit). S5 said on admission to the unit, patient #1 was placed on the ventilator at night and during the day she would do "great without it". She also said the patient did not want her gown or the dressing around her trach changed because patient #1 would complain of pain when the tracheostomy cannula was manipulated.

Further interview with S5RN revealed when a patient in the unit had an MDRO, the physician ordered antibiotics and the hospital placed the patient on isolation precautions. S5RN stated if a patient's culture revealed an MDRO, the infection control officer would call the unit and staff would place the patient in contact isolation. S5 also stated that she did not recall which organism patient #1 cultured. S5RN reported when cultures were completed, the results were sent to the unit electronically and the unit secretary printed the results and placed this information on the patient's paper chart (comprised of written physician orders, progress notes and laboratory results). She stated the lab reports were received throughout the day as preliminary results and at the end of that day the lab sent the final results by the pneumatic tube to the unit.

Interview with S1 infection control officer on 5/5/10 at 2:50 PM revealed after reviewing laboratory results, patient #1 should have been placed in contact isolation on 1/26/10 or 1/27/10 when the lab report indicated the patient had a multidrug-resistant Acinetobacter organism. The survey team reported to S1 there was no documented evidence to support patient #1 was in contact isolation.

A second interview with S1 infection control officer on 5/6/10 at 8:25 AM confirmed patient #1 was not placed in contact isolation. S1 also stated the RN on the unit could place a patient in contact isolation without a physician order, but the nurse should report that to the physician.

Patient #2
Review of the closed electronic medical record for patient #2 revealed he was admitted on 3/19/10 with diagnoses that included respiratory failure with acute carbon dioxide retention, probably secondary to Pickwickian syndrome (syndrome of severely obese patients who fail to breathe rapid or deeply enough), morbid obesity, hypertension, and sleep apnea. Review of the history and physical report revealed patient #2 "was seen by Pulmonary Services and was intubated". A sputum culture was obtained on 4/4/10 and lab results dated 4/6/10 indicated an infection from Acinetobacter baumannii. Further review of the medical record revealed no documented evidence to support patient #2 was placed in contact isolation for the MDRO as per the hospital's policy and procedure for isolation precautions.

Review of the Infection Control Policy # IC 4.11 (approved 4/08) revealed Infection Control should be alerted to the identification of a resistant organism in a timely manner. Further review revealed isolation precautions for patients with known or suspected MDRO infection/colonization should include that gown and gloves be worn when entering the room and removed prior to exiting the patient's room and equipment such as stethoscope and sphygmomanometer should be dedicated for use on that one patient only.

I. Based on review of 1 of 5 medical records and staff interviews, the RN failed to ensure the nursing staff kept current an ongoing assessment of the needs for each patient as evidenced by the failure of the RN to document a verbal order to rescind an order to transfer patient #1 from ICU2 to ICU. Findings:

Review of the medical record revealed on 1/28/2010 at 6:20 AM the attending physician ordered for patient #1 to transfer from ICU2 to ICU. In a telephone interview on 5/26/2010 at 2:20 PM, S23 Hospitalist stated he recalled when he ordered (in writing) for staff to transfer patient #1 from ICU2 to an ICU (critical care) bed. He stated on that morning (1/28/2010) he went to ICU2, assessed patient #1, and made a decision to transfer her to ICU. He stated at that time (6:35 AM) the critical care units were full and the ICU2 nurse manager asked could they keep the patient in ICU2 and have ICU nurses provide care. S23 indicated he agreed to the patient remaining in ICU2 until she could be transferred. He stated he did not say this to the nurse manager, but he thought the nurse understood what he meant.

Dr. S23 further stated he assumed the patient was transferred to ICU that day (1/28/2010) but when he went to the Hospitalist group meeting the following morning (1/29/2010), he learned patient #1 was not transferred as he had ordered. S23 said apparently the nurse manager misunderstood his consent for the patient to remain in ICU2 to mean that the transfer order was cancelled. He further stated it was not his intention for the patient to remain in ICU2. A thorough review of the medical record failed to reveal the ICU2 nurse manager documented a verbal order to rescind the 1/28/10 physician order to transfer the patient from ICU2 to ICU.


II. Based on record review the hospital failed to ensure the nursing staff followed the plan of care for 1 of 5 sampled patients (#1) by failing to follow physician orders for tracheostomy care. Findings:

Review of physician orders revealed on 12/30/2009 at 3:30 PM Dr. S13 ordered for patient #1 to have routine tracheostomy care twice daily. Review of the medical record revealed staff provided tracheostomy care at least twice daily except on 1/07, 1/11, 1/12/, 1/14, and 1/16-1/18/2010 which was only provided daily. Further review failed to reveal documentation that staff provided tracheostomy care on 1/15 and 1/19/2010. There failed to be documentation that the patient or her family refused tracheostomy care.

Based on review of 1 of 2 closed electronic medical records of patients with tracheostomies (patient #1) in a total sample of 5, review of the epidemiology report from 7/01/2009 to 5/06/2010 of patients with multi-drug resistant organisms (MDRO), review of hospital policies and procedures, and interviews, the hospital failed to meet the Condition of Participation for Infection Control as evidenced by:

1) the failure of hospital staff to be knowledgeable that the computer software, installed in June 2009, between the laboratory department and the infection control officer was performing the intended function of identifying and notifying the infection control officer of all MDROs since June 2009, or that the hospital had developed a back-up system should the computer system not function as intended. The hospital failed to ensure the infection control computer program was capable of identifying all organisms as evidenced by not identifying patients who developed Acinetobacter (multidrug resistant organism) since June, 2009. The hospital staff was unaware that the computer system interfaced between the laboratory and the infection control officer was not capturing and reporting Acinetobacter infections until the infection control officer was made aware on 5/5/10 by the surveyor of the positive lab reports for Acinetobacter identified in patients #1 and #2. As a result, the two patients were not placed in required isolation according to hospital policies and procedures. (See findings cited at A0749)

2) the failure of the hospital infection control officer to provide an accurate number of patients since June 2009 who had developed a positive lab report identifying Acinetobacter infections due to the lab computer system only alerting the Infection Control Officer for VRE (vancomycin resistant enterococcus), MRSA (methicillin resistant staphylococcus aureus) and C-Diff (clostridium difficile) from 06/09 until 5/5/10. (See findings cited at A-0750)

3) the failure of the Infection control Officer to ensure prevention and control of all infectious diseases, including ensuring patients, when required, are placed on contact precautions in order to prevent the spread of multidrug resistant organisms. (See findings cited at A-0395)

An Immediate Jeopardy situation was identified on 5/6/10 at 12:10 PM. The DON (director of nursing services) was notified of the immediate jeopardy at that time.

On 5/7/10 at 2:05 PM, the hospital submitted a plan of correction which included: 1) discontinuation of the current infection control software program which was linked with the lab system until the problem with the interface could be determined and 2) the initiation of policy MI.3085.01 titled, "Notification Procedure for Contact Isolation effective 5/07/2010 which included:

1) Contact isolation for Acinetobacter and all multidrug resistant organisms,
2) Lab will report to a responsible licensed caregiver within one hour after final culture report of an organism requiring contact isolation
3) Inpatient results will be called to the patient's nurse
4) Lab will report all pertinent information to the nurse and the nurse will read back the results
5) Lab will document the call on the Phone Action Log for Critical and MDRO (multidrug resistant organisms
6) Lab will generate a report of all positive cultures for that day and forward the report to the Infection Control Department and reviewed daily by the infection control nurse. The infection control department will contact the units to validate the patient with a MDRO has been placed in contact isolation and document the conversation in the MDRO log.
7) The Infection Control nurse will verify that contact isolation has been ordered and if not will investigate, take necessary corrective action which includes manager notification and an electronic incident report.
8) Data related to compliance with the process will be submitted to the appropriate oversight committee and any follow-up or recommendation by the committee will be conveyed to the infection control committee for implementation.

As a result of the submission of the corrective action plan, the Immediate Jeopardy was removed on 5/7/10 at 2:05 PM. The DON was informed at that time of the removal of the Immediate Jeopardy.

Non-compliance continued at a condition level.

Based on review of of 1 of 5 medical records of patients who had a MDRO (#1) and interviews, the infection control officer (S1) failed to ensure the reliability of the hospital's current system for alerting the infection control department of all infections requiring contact isolation. Findings:

An interview with S1 infection control officer on 5/3/10 at 11:30 AM revealed every patient who cultured a microorganism that indicated an infection after 48 hours of admission to the hospital would be "flagged" to her computer which meant the information was forwarded from lab to her computer. S1 confirmed there was hospital wide surveillance of MDROs (multi drug resistant organisms).

During the interview S1 stated the hospital followed CDC (Center for Disease Control) recommended criteria on what organisms infection control would track. She further indicated that the hospital utilized a computer program (Quantros) with a Dashboard that alerted the infection control department to any positive culture and when any patient in the hospital needed to isolation. S1 added the system also indicated what organism is hospital acquired (the infection developed 48 hours after admission) and when this occurs, she reviews the clinical record and gathers information to identify any trends or concern which enables the hospital to deploy resources should there be any trends.

In an interview on 5/05/2010 at 3:35 PM, S3 RN/Director of Quality reported the data from infection control audits goes to quarterly Quality Council meetings and then reported to medical staff. S3 indicated she was on the MRSA hand hygiene force committee but she had not seen any trends for infections in the critical care units. S3 also indicated the infection control officer (S1) and her staff received a call from lab when they have a positive culture requiring isolation and the infection control team double checks to verify the unit was using the correct isolation cart and the correct isolation instruction card to alert visitors and staff as to what personal protective equipment is needed for the type of isolation.

Review of the electronic medical record revealed patient #1 was admitted to the hospital on 12/9/09 with diagnoses that included bacterial pneumonia, urinary tract infection, malnutrition, and a form of muscular dystrophy. During the course of treatment, patient #1 required intubation, then a tracheostomy with night time ventilator support. As patient #1 improved, she was transferred to a stepdown unit, ICU2, on 1/22/10. While in ICU2, patient #1 developed a positive sputum culture with Acinetobacter baumannii- a multidrug resistant organism (MDRO) on 1/24/10. Further review of the medical record failed to reveal the patient was placed in contact isolation as per hospital policy for MDRO organisms.

Interview with S1 infection control officer on 5/5/10 at 2:50 PM revealed after reviewing patient #1's laboratory results, the patient should have been placed in contact isolation on 1/26/10 or 1/27/10 when the lab report indicated the patient had a MDRO. When the survey team reported to S1 there was no documented evidence to support patient #1 was placed in contact isolation, S1 indicated she was going to review patient #1's medical record to verify this because the lab tech should have alerted the infection control department of the positive culture. S1 stated her coworker would have made rounds the next day to ensure the correct type of isolation was initiated and that the correct signage card was used to list the personal protective equipment needed for the type of isolation. S1 further stated as a back-up to ensure isolation precautions were initiated, her department would also check to see if an isolation cart was obtained from the sterile processing department (SPD).

S1 stated the laboratory department would have a policy for the organisms they should alert the infection control department with and the alert would include an Acinetobacter organism. S1 stated at that time she did not know why the infection control department was not alerted that patient #1 had cultured an Acinetobacter organism because her department was tracking all patients with Acinetobacter when reported.

S1 further stated that she just realized after reviewing patient #1's medical record with the survey team that the hospital had a problem with the lab computer software program not alerting her department of all MDRO infections. S1 indicated she could not determine how many Acinetobacter infections her department had missed because she knew patient #1's culture results was not reported to her. S1 also indicated she depended on the computer soft ware (installed and ready for use July 2009) to alert infection control of all multidrug-resistant organisms.

Interview with S1 infection control officer on 5/6/10 at 8:25 AM revealed she looked for all patients who cultured an Acinetobacter organism from July 2009 when the new computer software was installed. S1 reported to the survey team that patient #1 was not listed on the printout of patients with positive cultures for Acinetobacter.

In an interview on 5/07/2010 at 1:00 PM, S1 infection control officer reported that the hospital's lab provided a comprehensive epidemiology report from 7/01/20109-5/06/2010 of all in-patients who cultured positive for an Acinetobacter organism. S1 stated after checking with the sterile processing department which supplied the isolation carts and comparing the information she received in her department with the report from lab, she found 8 patients who cultured Acinetobacter organisms which were considered multidrug resistant organisms, but they were not listed. S1 reported the patients were not placed in contact isolations and her computer system did not alert her that the patients had the organism. S1 further stated the hospital's system for reporting infections was not reliable at that time.

Based on review of the log of incidents related to infections and interviews with the Infection Control Officer and the Director of Quality, the hospital failed to maintain an accurate log of patients identified by laboratory culture as colonized or infected with MDROs (multi drug-resistant organisms), specifically Acinetobacter baumannii, as evidenced by 8 patients who had positive cultures for the organism.
Findings:

Interview with S1 Infection Control Officer on 5/6/10 at 8:25 AM revealed she looked for all patients with Acinetobacter organisms since July 2009 when a new computer software was installed. S1 indicated her printout did not list patient #1's name who had a positive sputum culture for an Acinetobacter organism. S1 further stated she did not understand the problem why the computer software did not alert her to all positive cultures which required isolation precautions. S1 indicated that the computer software should have alerted her of all MDROs.

During an interview on 5/07/10 at 1:00 PM, S1 Infection Control Officer reported after checking with SPD (sterile processing department which supplies the isolation carts) and comparing the information she received in her department, she found 8 patients were missed who cultured Acinetobacter infections (from 7/01/2009-5/06/2010). S1 indicated the 8 patients with Acinetobacter were considered multidrug resistant and the patients were not placed in contact isolation. S1 confirmed she kept an infection control log, but on 5/05/2010 she determined the log was inaccurate since the 8 patients with an Acinetobacter organism were not included in the log.

Based on review of 1 of 1 medical record of patients (#1) who sustained dental trauma during oral intubation as part of a surgical procedure in a total sample of 5, review of the hospital's anesthesia policies and procedures, and staff interviews, the anesthesia department failed to have a policy for dental trauma that occurred during oral intubation. Findings:

Review of the closed medical record revealed patient #1 was a 37 year-old who was admitted to the hospital on 12/09/2009 at 11:31 PM with complaints of shortness of breath, tachypnea, hypoxia, CO2 (carbon dioxide) retention, pleural effusions, lower extremity edema. The attending physician diagnosed the patient with bacterial pneumonia, urinary tract infection, malnutrition, and a form of muscular dystrophy. Review of nursing documentation revealed on 12/12/2009 at 12:35 AM patient #1 had respiratory arrest, was intubated and connected to a mechanical ventilator.

Further review of the medical record revealed on 12/30/2009 patient #1 could not be weaned from the ventilator and required a surgical tracheostomy. Review of the anesthesia record dated 12/30/2009 at 12:15 PM revealed placement of the tracheostomy tube was difficult and patient # 1 required the oral ET(endotracheal tube) be replaced. The ET tube was not placed until one of the hospitalists, who was an internist and pulmonologist, successfully placed the ET tube over a bronchoscope. Review of the Operative Report by surgeon and otolaryngologist Dr. S13 (dictated on 12/30/2009 at 3:04 PM) revealed, "It should be noted that in the course of the multiple attempts at intubation this patient orally with use of the laryngoscope, her two front tooth (teeth) were loosened". According to physician progress notes an oral surgeon removed the two teeth on 12/30/2009 at 4:35 PM.

An interview on 5/5/10 at 11:10 AM with Dr. S13 revealed patient #1's neck was deformed; very elongated, and her chin was very short due to her being a chronic mouth breather and the progression of her her muscular disorder. S13 also stated patient #1 had very poor oral hygiene and that her teeth moved with minimal pressure and during the difficult, multiple intubation attempts, patient #1's two front teeth moved. She said after the procedure, an oral surgeon was consulted to examine patient #1's teeth and he reported to her that the roots of the loosened teeth were not viable and that the teeth could not be salvaged.

An interview with Dr. S19 Anesthesiologist at 10:05 on 5/07/2010 revealed patient #1 had poor oral hygiene and her chin receded. S19 stated she had to struggle to get an airway in the patient. She also said that patient #1's teeth were "seated in the gums instead of the bone and were not in good shape". S19 stated when she brought the blade of the laryngoscope out of the patient's mouth, the edge touched the teeth, which were "holding by a thread", and they became loose.

In an interview on 5/05/2010 at 7:30 AM S4 CRNA (certified registered nurse anesthetist) indicated when teeth were damaged during oral intubation or the procedure, they informed the attending physician, the patient/family, and the company anesthesia services worked for. S4 stated a Quality Assessment form was completed after patient #1's tracheostomy describing the loss of patient #1's 2 front teeth and sent to the hospital's Quality Department.

During that interview S4 reviewed patient #1's 12/30/2009 tracheostomy anesthesia record and recalled the patient's intubation was very difficult and that they used all available intubation equipment (different laryngoscopes and sizes of endotracheal tubes) available to intubate the patient. S4 indicated that type of problem rarely happened but preoperatively anesthesia services questioned each patient if he/she has any loose teeth or caps and then they examine the teeth prior to intubation. S4 added they knew patient #1 would be a difficult intubation because of her anatomy (long neck and small mouth) and confirmed the documentation on the anesthesia record indicated how difficult it proved to be. During the interview S4 CRNA stated anesthesia services did not have an anesthesia policy for dental trauma. .

Based on review of nursing policies and procedures, the medical record for 1 of 5 sampled patients (#1), and staff interviews, the hospital failed to ensure policies and procedures governing medical care were developed which addressed a "silent code" in the critical care setting. Findings:

Review of the electronic medical record revealed patient #1 was a 37 year-old admitted to CCU (coronary care unit) on 12/10/2010 at 12:15 AM with shortness of breath, tachypnea, hypoxia, CO2 (carbon dioxide) retention, pleural effusions, and lower extremity edema. Review of admission nurses' notes revealed patient #1 was on BiPAP (positive airway pressure that helps the patient get more air into the lungs) which required frequent setting changes in response to her arterial blood gases which revealed increased amounts of carbon dioxide, the waste product of respiration, in the blood.

The medical record indicated on 12/12/2009 at 12:35 AM the CCU nurse documented patient #1 could not be aroused, had apnea episodes (no respirations) and agonal breathing (slow, 3-4 per minute irregular inspirations followed by irregular pauses) and a "silent code" (which was ordered by the attending physician and not announced over the hospital intercom) was initiated and the ER doctor responded immediately. During the code, the patient was intubated (endotracheal tube) and connected to a mechanical ventilator.

Review of nursing policies and procedures failed to reveal a policy which defined a "silent code" in order to provide direction to staff on how to manage and respond when a "silent code" was ordered. An interview on 5/24/10 at 10:45 AM with S18 DON revealed a "silent code" was an unofficial term for patients in the critical care setting who required resuscitation. S18 indicated the equipment was already there and most of the key personnel, but there was a need for additional help i.e. respiratory therapist or the physician, to complete the code team and the specific individual needed was contacted directly. S18 also confirmed the hospital did not have a policy related to a "silent code".

Based on review of the electronic medical record for patient #1, review of respiratory policies and procedures, and interviews, the hospital failed to ensure a written policy was developed and approved by the medical staff for ensuring respiratory equipment brought into the hospital and used by the patient is safe, functional, and adheres to hospital guidelines. Findings:

Review of the closed medical record for patient #1 revealed a physician order dated 1/14/2010 at 9:05 AM for the social worker to arrange for a home ventilator to allow the patient to adjust to the new ventilator and for family education prior to the patient's discharge. Further review revealed an employee of a medical supply company delivered the ventilator that day and respiratory therapy connected the patient to the machine. According to documentation in the medical record, patient #1 remained on the home ventilator until 1/29/2010 when the attending physician wrote an order to place the patient back on a hospital ventilator. In a telephone interview on 5/13/10 at 2:30 PM S3RN Director of Quality, confirmed respiratory services did not have a policy and procedure to evaluate a ventilator brought into the hospital and intended for home use to ensure the machine was functioning properly.