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Based on observation, staff interviews, and review of facility documents, it was determined that the facility failed to ensure an effective infection control program to prevent and control the spread of infectious diseases.

Findings include:

1. The facility failed to ensure that staff in the neonatal intensive care unit (NICU) wore facemasks in accordance with facility policy in two of seven patient treatment areas observed (Cross refer to Tag A 0749).

2. The facility failed to ensure that reusable infant feeding equipment is maintained in accordance with facility procedure for one of one type of reusable bottle observed (Cross refer to Tag A 0749).

3. The facility failed to ensure that reusable patient care equipment is disinfected in accordance with facility policy in two of three observations (Cross refer to Tag A 0749).

4. The facility failed to ensure that hand hygiene procedures are performed to minimize the spread of infection (Cross refer to Tag A 0749).

5. The facility failed to ensure that Super Sani-Cloth Germicidal Disposable Wipes container lids are kept closed when not in use in two of five treatment areas observed (Cross refer to Tag A 0749).

6. The facility failed to ensure that clean privacy curtains that were available for use, are stored in designated clean areas in the NICU. (Cross refer to Tag A 0749).

7. The facility failed to ensure that its MSSA/MRSA [Methicillin-Susceptible S. aureus/Methicillin-resistant S. aureus] Infection Control Plan was immediately implemented in response to a potential outbreak of MSSA for two of two MSSA colonized patients reviewed (Cross refer to Tag A 0750).

8. The facility failed to ensure that staff documented the implementation of contact precautions in accordance with provider orders for four of five NICU infants with contact isolation orders (Cross refer to Tag A 0750).

Based on observation, review of facility policy and procedure, and staff interview, it was determined that the facility failed to ensure that: 1) staff in the neonatal intensive care unit (NICU) wore facemasks in accordance with facility policy in two of seven patient treatment areas observed; 2) reusable infant feeding equipment is maintained in accordance with facility procedure for one of one type of reusable bottle observed (Dr. Brown's); 3) reusable patient care equipment is disinfected in accordance with facility policy in two of three observations; and 4) hand hygiene procedures are performed to minimize the spread of infection; 5) Super Sani- Cloth Germicidal Disposable Wipes container lids are kept closed when not in use in two of five treatment areas observed; and 6) privacy curtains used in patient rooms, that are available for use, are stored in designated clean areas in the NICU.

Findings include:

1. During a tour of the NICU on 4/17/23, staff were observed with facemasks below their nares as follows:

At 11:02 AM, Staff (S) 41, a Registered Nurse (RN), was observed in an occupied patient room in the "Small Baby" area with his/her the facemask below his/her nares. Upon interview, S41 stated that his/her mask "always falls down."

At 11:18 AM, a staff member was observed exiting the Clean Supply Storage area pushing a cart that contained a large box. The staff members mask was below his/her nares.

At 12:42 PM, in the Continuing Care area, S35, a RN, was observed entering a patient room to talk to the infant's family member at the bedside. S35 had his/her facemask below the nares while at the bedside.

At 1:16 PM, upon re-entry to the "Small Baby" area, S41 was observed at a patient bedside with his/her mask below the nares. Upon seeing the surveyor, S41 lifted his/her facemask to cover his/her nose.

At 1:40 PM, in the Continuing Care area, S35 was observed administering intravenous (IV) medication to an infant. S35 had his/her mask below the nares during the entirety of the procedure.

At 2:10 PM, in the Continuing Care area, S35 exited an occupied patient room with his/her mask below the nares.

Facility policy titled, "HMH COVID-19 Universal Pandemic Precautions for Patient Care Settings," last revised 12/2023, states, "... Protocol: A. Respiratory protection for Team Member, Physicians and Licensed Independent Practitioners (LIPs) ... e. TMs [team members], physicians and LIPs will be required to wear a mask, regardless of COVID-19 Level, in the following situations: ... ii. In a specific area of the hospital/facility identified by clinical leadership where highly vulnerable patients are receiving care (e.g. NICU) or there is a high risk of transmission (e.g. inpatient behavioral health unit)."

2. During a tour of the Continuing Care area of the NICU on 4/17/23 at 12:30 PM, staff were observed washing infant feeding bottles in the sink. S8, the NICU Educator, stated that the Dr. Brown's bottles are washed in the sink with dish detergent after each feeding and reused for 24 hours before being sent down to central processing for sterilization. S34, a Registered Nurse who normally works in the Mother/Baby unit, was asked about the process for cleaning the reusable bottles. S34 described the process and showed this surveyor a basin in which the bottle and its parts were currently drying for the bottle he/she had been observed washing. The basin also contained a silicone bottle brush that staff stated was dedicated to each infant and would also be sent down for sterilization. The bottle parts were drying on a white towel and/or wash cloth within the basin. This was not in accordance with the facility procedure which states that the bottle parts would be dried on a sterile towel.

On 4/18/24 at 10:45 AM, S22 and S23, both NICU Charge RN's, stated that the sterile towels used for drying bottles and their parts are blue not white. Staff confirmed that the white towels observed being used for drying were not sterile.

On 4/17/24 at 12:49 PM, two silicone bottle brushes were at the sink near the door to the Transition room. Upon interview, S8 could not say why the bottle brushes were at the sink or to which baby they belonged. S8 asked the RN's working in Continuing Care area if anyone knew the reason the bottle brushes were left at the sink and staff were unable to identify why they were left at the sink as each baby using reusable bottles on the unit had a dedicated brush. S8 stated that the bottle brushes would be removed.

Facility procedure titled, "Dr. Brown Bottle Cleaning Guideline," last revised 08/2019, states, "... 2. Patient Use Process a. At the start of the day shift (7 am), the nurse will pick up a sterilized bottle system, nipple, new wire cleaning brush and new bottle brush b. The bottle, nipple, small wire cleaning brush and bottle brush once opened can be used for 24 hours. ... e. The bottle brush will be sanitized daily by central processing ... 3. Cleaning instructions after each use ... Rinse all bottle components, and place to air dry on a sterile towel in the clean basin located in the patient's room. ..."

3. During tour of the Small Baby area on 4/17/24 at 1:23 PM, S36, a RN, was observed at the bedside in the Small Baby area. S36 returned a glucometer (a device used to measure the concentration of glucose in the blood) to a nurse's station and was then asked about the process for cleaning the glucometer after use. S36 stated that he/she had already cleaned the glucometer prior to returning it to the nurse's station and that he/she had used a "purple top" wipe (Super Sani Cloth) for 1 minute. This was not in accordance with facility policy which was to use a bleach wipe. This was confirmed with S8 who stated that the "purple top" wipes were an approved disinfectant but that bleach wipes were to be used per facility policy.

Facility policy titled, "Blood Glucose Monitoring at Point of Care Testing Sites," last revised 04/2024, states, "... Section F: Cleaning and Maintenance ... Cleaning guidelines 1. Meters MUST be disinfected with PDI bleach wipes in between each patient and allowed to dry for the full disinfectant time of 4 minutes. Use of other chemicals could result in meter damage. ..."

During a tour of the Continuing Care area on 4/17/24 at 1:40 PM, S35 was observed exiting a patient room with gloved hands and placing a scanner used for medication administration onto a holder at the nurse's station. Staff then returned to the patient's bassinet and connected the IV medication to the patient's IV tubing and administered the medication. S35 did not clean the scanner after removing it from the patient's room and before placing it at the nurse's station. S8 stated that the scanner should be cleaned with a "purple top" wipe when it comes out of a patient room after use. At 1:49 PM, S35 was asked about the cleaning of the medication scanner. S35 stated that there was no protocol for the cleaning of the scanner and that "[I] guess you can use the purple top wipes."

On 4/18/24 at 10:45 AM, S22 and S23, both NICU Charge RN's, stated that the scanner in the "Sunshine Room" (the Continuing Care area) is the only place where a medication scanner is not dedicated to each patient. Staff stated that the scanner should be sanitized after each use.

Facility policy titled, "Care and Maintenance of Patient Environment and Equipment," last revised 12/2023, states, "... Policy: ... Equipment and the surrounding environment in all departments shall be cleaned and have low level disinfection performed according to manufacturer's instructions routinely, before/after patient contact, and when visibly soiled."

4. During a tour of the Continuing Care area on 4/17/24 at 1:40 PM, S35 was observed exiting a patient room with gloved hands and placing a scanner used for medication administration onto a holder at the nurse's station. S35 then returned to the patient's bassinet and connected the IV medication to the patient's IV tubing and administered the medication. S35 did not remove his/her gloves and perform hand hygiene after using the medication scanner and prior to administering IV medication.



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On 4/17/24 at 11:25 AM, during a tour of the NICU, S12, an Equipment Technician, cleaned and disinfected a Giraffe OmniBed with PDI Super Sani-Cloth Germicidal Disposable Wipes, in the Soiled Holding Room.

At 11:54 AM, during the observation, S12, with gloved hands, wiped the mattress of the OmniBed with a Super Sani-Cloth then placed the mattress on the pan portion of the OmniBed. S12 then removed his/her gloves, did not perform hand hygiene, reapplied new gloves and wiped the mattress again with a Super Sani-Cloth. At 12:02 PM, while wearing the same gloves, S12 cleaned two gasket pieces of the OmniBed then placed them on a countertop in the room. S12 then removed his/her gloves, did not perform hand hygiene, and then reapplied new gloves and proceeded to reassemble the OmniBed with the cleaned equipment.

On 4/17/24 at 1:45 PM, S18, EVS (Environmental Service), cleaned and disinfected patient room in the Continuing Care Area, after the patient who had occupied the room was transferred to another room in the NICU.

At 1:48 PM, S18, with gloved hands, cleaned and disinfected a freestanding refrigerator in the room then removed his/her gloves, did not perform hand hygiene, and applied a new pair of gloves. S18 then removed PDI Super Sani-Cloth Germicidal Disposable Wipes from an EVS cart located outside of the room, re-entered the room, and proceeded to wipe down the patient monitor, the monitor screen, the cords attached to the monitor, the wall mounted thermometer and other wall mounted equipment. S18 then exited the room, removed his/her gloves, did not perform hand hygiene, and applied new gloves. S18 then removed PDI Sani-Cloth Bleach Germicidal Disposable Wipes from a container located on the EVS cart outside of the room, re-entered the room and wiped down a chair.

Upon interview on 4/18/24 with S19, Director of Infection Control, confirmed that S12 and S18 should have performed hand hygiene between glove changes when cleaning and disinfecting the patient environment, equipment, and surfaces.

Facility policy titled, "Hand Washing and Hand Hygiene," last revised 12/2021, stated, " .... Procedure: ... C. Hand Washing/Hand Hygiene Indications ... after contact with ... environment. ... after removing gloves. ..."

5. On 4/17/24 at 12:26 PM, during a tour of the NICU, a container of Super Sani-Cloth Germicidal Disposable Wipes, used by staff for the cleaning and disinfection of patient care equipment, was observed on top of an equipment cart located outside of a room in Annex B, with the lid open. Upon discovery, an interview was conducted with S14, a Registered Nurse, who explained that the lid should be closed, and that a staff member had probably cleaned something earlier and did not close it.

At 1:38 PM, during a tour of the Continuing Care area of the NICU, another open container of Super Sani-Cloth Germicidal Disposable Wipes with the lid open, was observed on top of a bedside equipment cart located outside of a room. There were no observed staff members utilizing the wipes upon discovery.

On 4/18/24 at 11:56 AM, S15, EVS Group Leader, provided the facility document titled, "[facility name] Approved Disinfectants" that stated, "Germicidal Wipes (Purple Top) Super Sani-Cloth Germicidal Disposable Wipes ... Used to clean & disinfect equipment ... keeping the container closed after use ..."

6. On 4/17/24 at 12:35 PM, during a tour of the NICU, the Housekeeping Closet, located in a hallway within the NICU, contained an EVS (Environmental Services) cart, and housekeeping supplies and equipment. In the closet was an open box of "On the Right Track Holistipure Magic Waves Recyclable Curtains" that S15, EVS Group Leader, stated were the privacy curtains used in patient rooms. The box contained a large pack of curtains that were unopened, covered in clear plastic and available for use. Upon interview at the time of discovery, S15 stated, "we usually store them here so that the EVS staff can have them handy to change in the rooms." S19, Director of Infection Control, who was also present at the time of discovery stated, "they should be stored in the Clean Supply room."

Based on medical record review, review of documents, and staff interview, it was determined that the facility failed to ensure that: 1) its MSSA/MRSA [Methicillin-Susceptible S. aureus/Methicillin-resistant S. aureus] Infection Control Plan was immediately implemented in response to a potential outbreak of MSSA for two of two MSSA colonized patients reviewed (Medical Record [MR] 6 and 7); and 2) staff documented the implementation of contact precautions in accordance with provider orders for four of five Neonatal Intensive Care Unit (NICU) infants with contact isolation orders (MR3, 4, 5, and 6).

Findings include:

1. A review of the "MSSA/MRSA Infection Control Plan" developed by the facility and placed into effect on 4/16/24, in response to an increased number of Bacteremia cases caused by MSSA, indicated the following: "In collaboration with the hospital Infection Control team and Epidemiologists, the NICU has developed a plan for testing, isolation, and decolonization of identified patients. Testing: (effective immediately) All patients will be swabbed on Tuesday and Friday mornings ... Isolation: (effective immediately) Contact isolation for all patients testing positive for MSSA or MRSA ... Decolonization: (effective immediately) Treatment for any patient who tests + [positive] for MSSA or MRSA ... Prophylactic treatment for any high risk patient ... Birth gestational age [less than or equal to] 32 weeks ... Birth Weight [less than or equal to] 1500 grams ... Current Central Line ... Treatment: (effective immediately) Mupirocin 2% ointment [used to treat skin infections caused by bacteria] BID [twice daily] x [times] 5 days ..."

A review of MR6 revealed that swabs were sent for S. aureus testing on 4/16/24 and a positive result for MSSA was documented on 4/16/24 at 1740 [5:40 PM]. Contact isolation was ordered on 4/17/24 at 10:27 AM, 16 hours and 47 minutes after the result was determined and documented by the laboratory. Mupirocin 2% ointment was ordered on 4/17/24 at 11:01 AM, 17 hours and 21 minutes after the result was determined and documented by the laboratory.

A review of MR7 revealed that swabs were sent for S. aureus testing on 4/16/24, and a positive result for MSSA was documented on 4/16/23 at 2004 [8:04 PM]. Contact isolation was ordered on 4/17/24 at 10:19 AM, 14 hours and 15 minutes after the result was determined and documented by the laboratory. Mupirocin 2% ointment was ordered on 4/17/24 at 11:07 AM, 15 hours and 7 minutes after the result was determined and documented by the laboratory.

During an interview with S22 and S23, both Neonatal Intensive Care Unit (NICU) Charge Registered Nurse's (RN), on 4/18/24 at 2:35 PM, staff stated that the reason for the delay in orders was because the tests resulted at night.

On 4/19/24 at 10:15 AM, S32, the Microbiology Supervisor, was interviewed. S32 stated that the laboratory operates 24 hours per day, seven days per week. S32 stated that the laboratory staff was not given any special instruction regarding notification of positive MSSA results and stated that staff would not typically notify nursing staff of a positive MSSA test.

On 4/19/24 at 10:20 AM, the above timeline for the results of positive MSSA colonization results to provider orders entered in accordance with the facility "MSSA/MRSA Infection Control Plan" was confirmed with S19, the Director of Infection Control, in the presence of S1, the Director of Regulatory Affairs. S19 stated that since positive MSSA patients are not usually isolated or treated the results were not flagged as abnormal. S1 stated that the hospital's electronic system would not automatically flag a positive MSSA result. S1 and S19 confirmed that there was no process initiated to communicate the MSSA test results as they became available, which resulted in the above delay in implementation of the "MSSA/MRSA Infection Control Plan."

2. A review of MR3 revealed that an order for contact isolation was entered by the provider on 4/16/24 at 1551 (3:51 PM). Nursing documentation in the "Precautions" section of the flowsheet indicated that the infant was on "Universal" precautions on 4/16/2024 at 0800 (8:00 AM) and was changed to "Contact isolation" at 1910 (7:10 PM), three hours and 19 minutes after the order was entered by the provider.

A review of MR4 revealed that an order for contact isolation was entered by the provider on 4/16/24 at 1526 (3:26 PM). Nursing documentation the "Precautions" section of the flowsheet indicated that the infant was on "Universal" precautions on 4/16/24 at 0730 (7:30 AM) and 1900 (7:00 PM). The precautions were documented as "Contact isolation" on 4/17/24 at 0830 (8:30 AM), 17 hours and four minutes after the provider order was entered.

A review of MR5 revealed that an order for contact isolation was entered by the provider on 4/16/24 at 1535 (3:35 PM). Nursing documentation in the "Precautions" section of the flowsheet indicated that the infant was on "Universal" precautions on 4/16/2024 at 0730 (7:30 AM) and was changed to "Contact isolation" at 1930 (7:30 PM), three hours and 55 minutes after the order was entered by the provider.

A review of MR6 revealed that an order for contact isolation was entered by the provider on 4/17/24 at 1027 (10:27 AM). Nursing documentation in the "Precautions" section of the flowsheet indicated that the infant was on "Contact isolation" as of 1920 (7:20 PM), eight hours and 53 minutes after the order was entered by the provider.

During an interview on 4/18/24 at 12:32 PM, S23 stated that staff do not update the medical record when contact isolation is initiated and will document a change in precautions with the next assessment.

Facility policy titled, "Nursing Documentation" last revised 04/2022, states, "... Key Points: ... Document all interventions and reassessment of the interventions and any observable changes in the patient's general condition, his symptoms and behavior, and ongoing evaluation of the current status of the patient."