HospitalInspections.org

Based on policy review, Performance Improvement plan review, staff interview, open medical record review, telemetry audit tool review, infection control data review, job description review, and patient interview, the hospital's Governing Body failed to provide oversight and have systems in place to ensure an effective quality assessment and performance improvement program, an organized nursing service, and an effective infection control program to ensure the safety of patients.

The findings include:

1. The hospital failed to implement and maintain an effective quality assessment and performance improvement program to ensure the safety of patients.

~cross refer to 482.21 Quality Assessment/Performance Improvement Condition: Tag A0263

2. The hospital failed to have an organized nursing service providing oversight of day-to-day operations to ensure registered nursing staff supervised and evaluated patient care and administered medications per physician's orders.

~cross refer to 482.23 Nursing Services Condition: Tag A0385

3. The hospital failed to have a system in place to ensure the prevention and control of infections and communicable diseases.

~Cross refer to 482.41 Infection Control Condition: Tag A0747

Based on policy review, Performance Improvement plan review, staff interview, open medical record review, telemetry audit tool review, and infection control data review, the hospital failed to implement and maintain an effective quality assessment and performance improvement program to ensure the safety of patients.

The findings include:

1. The hospital failed to track identified quality indicators for telemetry patients by failing to accurately complete telemetry audit tools.

~cross refer to 482.21(a)(2) QAPI Standard: Tag A0267

2. The hospital failed to ensure quality of care by failing to monitor compliance with isolation policies and procedures in the hospital's Emergency Department.

~cross refer to 482.21(c)(1) QAPI Standard: Tag A0285

Based on policy review, Performance Improvement plan review, staff interview, open medical record review, and telemetry audit tool review the hospital failed to track identified quality indicators for telemetry patients by failing to accurately complete telemetry audit tools for 2 of 9 sampled patients on telemetry monitors (Patients #10 and #9).

The findings include:

Review of current hospital policy entitled "Telemetry Policy" dated 01/06/2012 revealed, "...Monitoring Practices of the Nurse or Monitor Technician (MT) assigned to a central monitoring unit:...Print a 6-second telemetry strip:...Every 4 hrs (hours)....Interpret rhythm strip. Record date, time, and name of MT/Nurse performing measurements and interpretation. Notify Primary Nurse for changes in patient's usual heart rate/rhythm. Provide copies of strips to Primary Nurse...."

Review of current hospital "PI (Performance Improvement) Plan 2011-2012" approved by the Board of Trustees 12/2011 revealed, "...Data will be collected and performance monitored regularly as determined by the leaders, for the following areas: Priorities identified by leaders....When an indicator detects or suggests significant undesirable performance or variation, intense analysis is initiated to determine where best to focus changes for improvement...."

Interview on 01/24/2012 at 1400 with the Interim Chief Nursing Officer (CNO) revealed an action plan to improve quality of care to patients on telemetry monitors had been implemented and audits to monitor the process were currently in process. Interview revealed all patients on telemetry monitors on inpatient units are audited each day. Interview revealed the Monitor Tech completes the Telemetry Audit Form for the previous 24 hour period every morning and gives it to the manager. Interview revealed the Telemetry Audit Form includes documentation of cardiac rhythm changes, nurses' responses to rhythm changes, and presence of a rhythm strip (printed, interpreted and signed) in the medical record every 4 hours. Further interview revealed the manager reviews all of the Telemetry Audit Forms daily and completes the Nursing Telemetry Summary Audit Tool. Interview revealed the manager documents rhythm alerts and staff follow up, as well as whether or not any rhythm strips were missing from the medical record. Further interview revealed all completed Nursing Telemetry Summary Audit Tools are sent to nursing administration daily data aggregation and review.

1. Medical record review on 01/25/2012 during tour of the 8-South Unit for Patient #10 revealed a 79 year-old female that was admitted on 01/17/2012 from a skilled nursing facility with sepsis, urinary tract infection, bilateral lower extremity cellulitis, and renal failure. Record review revealed a physician's order dated 01/17/2012 at 1515 for telemetry monitoring (continuous heart monitoring) of the patient. Record review revealed no documentation of a printed 6-second telemetry strip, interpreted and signed by a MT or nurse, between 01/23/2012 at 1559 and 01/24/2012 at 0430 (12 hours and 31 minutes - 2 rhythm strips missing from record). Record review revealed a physician's order dated 01/24/2012 at 1100 to discontinue telemetry monitoring of the patient.

Review of Telemetry Audit Forms for Patient #10 revealed no form dated 01/23/2012. Review of the Nursing Telemetry Summary Audit Tool for 8-South dated 01/24/2012 revealed documentation of the nurse manager's review of Telemetry Audit Forms from the previous day (01/23/2012). Review of the Tool revealed no documentation Patient #10 had been reviewed.

Interview on 01/25/2012 at 1500 with the Nurse Manager of the 8-South Unit revealed the Unit has 34 rooms, numbered 1 through 34. Interview revealed all of the beds have telemetry monitoring capability, but rooms 1 through 32 are routinely used for telemetry patients. Interview revealed Patient #10 was in room 33, which was not a room that usually had telemetry patients in it. Interview revealed, "I didn't audit (room) 33 (on 01/24/2012) because I stopped at (room) 32 and I didn't have an audit sheet (Telemetry Audit Form). I'm not sure why I didn't have an audit sheet for her. The monitor tech on night shift going off (duty) should have given it to the dayshift Unit Secretary to check and make sure the strips were in the chart and signed by the (monitor) tech." Interview revealed the telemetry audit process did not detect the fact that telemetry strips were missing from the patient's medical record.

2. Medical record review on 01/25/2012 during tour of the 6-South Unit for Patient #9 revealed a 26 year-old female that was admitted on 01/18/2012 with diabetes and sickle cell crisis. Record review revealed a physician's order dated 01/18/2012 at 1815 for telemetry monitoring (continuous heart monitoring) of the patient. Record review revealed no documentation of a printed 6-second telemetry strip, interpreted and signed by a MT or nurse, on 01/20/2012 between 1207 and 1951 (7 hours and 44 minutes). Record review revealed a physician's order dated 01/22/2012 at 2115 to discontinue telemetry monitoring of the patient.

Review of a Telemetry Audit Form dated 01/20/2012 for Patient #9 revealed no documentation of any missing telemetry strips on 01/20/2012. Review of the Nursing Telemetry Summary Audit Tool for 6-South dated 01/21/2012 revealed documentation of the nurse manager's review of Telemetry Audit Forms from the previous day (01/20/2012). Review of the Tool revealed documentation Patient #9 had been audited and found to have no missing telemetry strips.

Interview on 01/25/2012 at 1320 with the Nurse Manager of the 6-South Unit revealed, "Resource nurses do audits of telemetry patients every shift." Interview confirmed the missing telemetry strip from 01/20/2012 was not noted on either the Telemetry Audit Form or the Nursing Telemetry Summary Audit Tool. Interview revealed the telemetry audit process did not detect the fact that a telemetry strip was missing from the patient's medical record.

Based on review of hospital policy, infection control data and staff interviews, the hospital failed to ensure quality of care by failing to monitor compliance with isolation policies and procedures in the hospital's Emergency Department.

The findings include:

Review of the hospital's Patient Safety Plan, effective 12/2011, revealed, "....(Name of Hospital) integrates activities to improve patient safety and to proactively address and reduce medical/health care occurrences and other factors that contribute to unintended and/or unanticipated adverse patient outcomes. It is our responsibility to question if we can do things in a better, more efficient, and safer manner and be relentless in our pursuit of finding ways to improve our systems and to establish patient safety priorities for the health system....In the organization's commitment to quality, there is a focus on improving these systems and processes...."

Review of the hospital's infection control data dated 07/18/2011, 08/23/2011, 09/19/2011, 10/19/2011, 11/14/2011 and 01/02/2012 revealed "Contact Isolation Compliance Scores" for patient care units of the hospital. Review of the data revealed no contact isolation compliance score for the hospital's Emergency Department (ED).

Interview on 01/25/2012 at 1030 with the hospital's Interim Emergency Department Director revealed, "We are not monitoring compliance with isolation in the ED. We haven't done that in months."

Interview on 01/24/2012 at 1515 with the Infection Control Practitioner revealed, "The ED patients are not really included on the Infection Control log. There is no monitoring for compliance with isolation in the ED. We don't have a really good handle on this." Further interview on 01/26/2012 at 1150 revealed, "The last time the ED was monitored for compliance with isolation was in April (2011 - 9 months ago). I knew this sometime between June (2011) and August (2011). I had a conversation with (ED resource nurse). I haven't followed up." Interview further revealed the contact isolation compliance data is reported to the Patient Safety/Quality Council. Interview revealed the Patient Safety/Quality Council has not questioned the lack of monitoring for isolation precautions in the ED.

Interview on 01/26/2012 at 1140 with the hospital's Director of Quality revealed, "Compliance with isolation falls with the Infection Control Department. They have weekly Infection Control meetings and quarterly meetings with the Infection Control Committee. The Infection Control Committee reports to the Patient Safety/Quality Council and the information is then reported to the Board Quality Committee." Interview further revealed, "We did not realize the ED was not being monitored for compliance."

Based on policy review, open medical record review, and staff interview the hospital failed to have an organized nursing service providing oversight of day-to-day operations to ensure registered nursing staff supervised and evaluated patient care and administered medications per physician's orders.

The findings include:

1. The hospital's nursing staff failed to supervise and evaluate patient care by failing to review and interpret telemetry monitor tracings to assess cardiac rhythms of patients on telemetry monitors per policy.

~cross refer to 482.23 (b)(3) Nursing Services Standard: Tag A0395

2. The hospital failed to ensure nursing staff administered insulin as ordered by the physician.

~cross refer to 482.23 (c) Nursing Services Standard: Tag A0404

Based on policy review, open medical record review, and staff interview the hospital's nursing staff failed to supervise and evaluate patient care by failing to review and interpret telemetry monitor tracings to assess cardiac rhythms of patients on telemetry monitors per policy for 2 of 9 sampled patients on telemetry monitors (Patients #10 and #9).

The findings include:

Review of current hospital policy entitled "Telemetry Policy" dated 01/06/2012 revealed, "...Monitoring Practices of the Nurse or Monitor Technician (MT) assigned to a central monitoring unit:...Print a 6-second telemetry strip:...Every 4 hrs (hours)....Interpret rhythm strip. Record date, time, and name of MT/Nurse performing measurements and interpretation. Notify Primary Nurse for changes in patient's usual heart rate/rhythm. Provide copies of strips to Primary Nurse...."

1. Medical record review on 01/25/2012 during tour of the 8-South Unit for Patient #10 revealed a 79 year-old female that was admitted on 01/17/2012 from a skilled nursing facility with sepsis, urinary tract infection, bilateral lower extremity cellulitis, and renal failure. Record review revealed a physician's order dated 01/17/2012 at 1515 for telemetry monitoring (continuous heart monitoring) of the patient. Record review revealed no documentation of a printed 6-second telemetry strip, interpreted and signed by a MT or nurse, between 01/23/2012 at 1559 and 01/24/2012 at 0430 (12 hours and 31 minutes). Record review revealed a physician's order dated 01/24/2012 at 1100 to discontinue telemetry monitoring of the patient.

Interview on 01/25/2012 at 1500 with the Nurse Manager of the 8-South Unit revealed monitor tech or nurse should print, interpret, and sign telemetry monitor strips every 4 hours. Interview revealed the strips should then be placed in the medical record. Interview confirmed there was no available documentation of a printed 6-second telemetry strip, interpreted and signed by a MT or nurse, between 01/23/2012 at 1559 and 01/24/2012 at 0430 (12 hours and 31 minutes).

2. Medical record review on 01/25/2012 during tour of the 6-South Unit for Patient #9 revealed a 26 year-old female that was admitted on 01/18/2012 with diabetes and sickle cell crisis. Record review revealed a physician's order dated 01/18/2012 at 1815 for telemetry monitoring (continuous heart monitoring) of the patient. Record review revealed no documentation of a printed 6-second telemetry strip, interpreted and signed by a MT or nurse, on 01/20/2012 between 1207 and 1951 (7 hours and 44 minutes). Record review revealed a physician's order dated 01/22/2012 at 2115 to discontinue telemetry monitoring of the patient.

Interview on 01/25/2012 at 1320 with the Nurse Manager of the 6-South Unit revealed monitor tech or nurse should print, interpret, and sign telemetry monitor strips every 4 hours. Interview revealed the strips should then be placed in the medical record. Interview confirmed there was no available documentation of a printed 6-second telemetry strip, interpreted and signed by a MT or nurse, on 01/20/2012 between 1207 and 1951 (7 hours and 44 minutes).

Based on policy review, open medical record review, and staff interview the hospital failed to ensure nursing staff administered insulin as ordered by the physician for 1 of 5 sampled patients with physicians' orders for sliding scale insulin (Patient #9).

The findings include:

Review of current hospital policy entitled "Medication Administration" dated 01/11/2012 revealed, "I. GENERAL POLICY:...B. Medication orders are originated by a License independent Practitioner....F. Remove medications from the Pyxis for one patient at a time and administer to each patient separately, adhering to the 'five fights of medication' administration as follows:...3) right dose....II. SECOND NURSE VERIFICATION:....A. High alert medications and specific critical medications require a second licensed nurse, one being a RN (registered nurse), to check the five rights before administration...."

Medical record review on 01/25/2012 during tour of the 6-South Unit for Patient #9 revealed a 26 year-old female that was admitted on 01/18/2012 with diabetes and sickle cell crisis. Review of physician's orders dated 01/18/2012 at 1815 revealed, "...sliding scale insulin BS-100/30 (BS level minus 100 and then divided by 30 to get the dose of insulin to be administered) & accucheck (blood sugar test) Q ACHS (before each meal and at bedtime)...." Record review revealed on 01/24/2012 at 2344 (bedtime) the patient's blood sugar was 308. Record review revealed RN #5 administered 10 units of insulin to the patient on 01/24/2012 at 2353 (blood sugar of 308 minus 100 and then divided by 30 equals 6.9, so the dose of insulin that should have been administered was 7 units). Record review revealed RN #6 checked the insulin dose with RN #5 prior to administration.

Interview on 01/25/2012 at 1320 with the Nurse Manager of the 6-South Unit revealed, based on the patient's blood sugar of 308, the patient should have been given 7 units of insulin on 01/24/2012 at 2353. Interview confirmed RN #5 administered 10 units of insulin to the patient on 01/24/2012 at 2353. Interview revealed, "This was a med(ication) error."

Based on policy review, job description review, staff interview, open medical record review, and patient interview, the hospital failed to have a system in place to ensure the prevention and control of infections and communicable diseases.

The findings include:

1. The hospital's Infection Control Officer failed to ensure the control of infections by failing to ensure isolation precautions were initiated per hospital policy.

~Cross refer to 482.41 (a)(1) Infection Control Standard: Tag A0749

Based on policy review, job description review, staff interview, open medical record review, and patient interview, the hospital's Infection Control Officer failed to ensure the control of infections by failing to ensure isolation precautions were initiated per hospital policy for 7 of 9 patients presenting to the hospital with a history of infectious/communicable disease (#13, #14, #12, #20, #9, #10, #21).

The findings include:

Review of the hospital's policy, "Isolation Precautions", revised 01/2011, revealed, "Policy: Isolation Precautions are used in addition to Standard Precautions when patients have or are suspected of having a highly communicable disease or a disease of epidemiological importance....The nurse may place the patient on isolation without a physician's order per this policy....Purpose: To utilize control measures, which decrease the risk of transmission of microorganisms within the Health System....Guidelines:...II. Transmission-Based Precautions: A. General Principles: 1. In addition to Standard Precautions, use Isolation Precautions for patients with documented or suspected infection or colonization with highly transmissible or epidemiologically important pathogens for which additional precautions are needed to prevent transmission....B. Contact Precautions: There are two types of Contact Precautions. Contact Precautions and Contact-Special Enteric Precautions. Use Contact Precautions, for specified patients known or suspected to be infected, colonized, or known exposure to communicable diseases which may spread prior to development of signs or symptoms with epidemiological important microorganisms that can be transmitted by direct contact with the patient (hand or skin-to-skin contact that occurs when performing patient-care activities that require touching the patient's dry skin) or indirect contact (touching) with environmental surfaces or patient-care items in the patient's environment. Contact-Special Enteric Precautions are used for highly transmittable diarrhea illnesses caused by Clostridium difficile or Norovirus. 1. Automatically place patient on Contact Precautions when patients are identified as having Methicillin Resistant Staphylococcus Aureus (MRSA), Vancomycin Resistant Enterococcus (VRE)...2. Patients flagged in SMS or Valley Link (hospital computer system), as MRSA, VRE...positive are to be automatically placed on Contact Precautions with each visit to the Health System per order of the Infection Prevention and Control Committee. Registration staff places blue armband on these patients. Nursing is responsible for placing the blue armband on patients identified during their hospital stay. 3. Patients flagged as having a history of MRSA are to remain on Contact Precautions until 6 months has lapsed from the last positive MRSA culture and there are 2 negative cultures for MRSA from nares and other site of infection (if present)....4. Patients flagged, as having a history of VRE are to remain on Contact Precautions until 1 year has lapsed from last positive culture, and there are 3 successive rectal swabs obtained for VRE at least 1 week apart. 5. Automatically place patient on Contact-Special Enteric Precautions when Clostridium difficile toxin is ordered or patient is known or suspected as having Clostridium difficile or Norovirus as the cause of diarrhea...."

Review of the hospital's policy, "Triage Policy-Adult", revised 06/20/2011, revealed, "POLICY: Patients presenting to the Emergency Department are evaluated by a Registered Nurse to determine the nature of their presenting complaints, their condition...B. Initial Intake Process:...Secondary Triage includes:...f. Pertinent past medical history...."

Review of the hospital's job description for the director of infection prevention and control, revised 03/2010, revealed, "...Job Summary: The Director of Infection Prevention and Control is a registered professional nurse who is responsible for supervising the multiple facets of the Infection Prevention and Control Program in the institution....Major Job Functions:...B. Surveillance and Reporting Functions:...4. Oversees Infection Preventionists, Infection Prevention and Control Coordinator's surveillance rounds and accuracy of surveillance....C. Prevention Functions:...2. Coaches and mentors Infection Preventionists and Infection Prevention and Control Coordinator with assisting department manager in achieving compliance with established infection control and prevention priorities and/or system goals...."

Interview on 01/24/2012 at 1400 with the hospital's infection control practitioner revealed patients that present to the hospital with a history of MRSA or VRE should be placed on Contact Isolation precautions as soon as possible. Interview revealed patients that present to the hospital and are suspected to have Clostridium difficile toxin (C-Diff) should be placed on Special Enteric precautions as soon as possible. Interview revealed, "When a patient is registered in the ED, the business office uses INVISION (computer system) to register the patient." Interview revealed the alert for isolation precautions related to a history of infectious disease is displayed in the INVISION computer system. Interview further revealed, "The registrar places a blue arm band on the patient and tells the nurse. The nurse should document in the ED record. The alert for isolation precautions is not in EMSTAT (ED clinical computer system)."

1. Medical record review of Patient #13 revealed a 41 year-old who presented to the hospital's emergency services department via EMS (emergency medical services) on 01/19/2012 at 1427 with chief complaint of right lower abdominal pain and fever. Review of the ED record revealed the patient's temperature was 102.8 degrees when assessed by the triage nurse at 1431. Review of the ED record revealed documentation by RN #1 at 1433, "...TB Screening: Have you been exposed to TB- no, Have you had a cough or resp (respiratory) illness -no, Fever greater than 100.4 Fh (Fahrenheit) or 38 C (Celsius)- No...Isolation Recommended: No...." Record review revealed Patient #13 was admitted to an inpatient unit on 01/20/2012 at 1426. Review of the SBARR (nurse-to-nurse communication tool) ED Admission Report for Patient #13 revealed, "...Pt. Status & Alerts: Isolation: *Standard Precautions...." Review of the electronic medical record for Patient #13 revealed a red exclamation mark (!) in the left upper corner of the screen. Review of the "Alert Description" that opened after clicking on the exclamation mark (!) revealed, "....MRSA Present: flank on 10/23/2009. Place on Contact Precautions with each visit...." Further record review revealed Contact Isolation was ordered by a nurse on 01/23/2012 at 0909 (3 days, 18 hours after presentation to the hospital).

Interview on 01/25/2012 at 0915 with RN #1 revealed the nurse was working in the hospital's ED on 01/19/2012 as the triage nurse. Interview revealed the nurses in the ED do not have access to the computer system that displays alerts for isolation precautions. Interview revealed ED registration personnel have access to the alerts and the nurses depend on the registrars to place blue arm bands on patients that should be isolated. Interview revealed Patient #13 did not have a blue arm band on when triaged. Interview revealed, "If I had known, I would have notified the provider so the doctor could order precautions." Interview further revealed, "Nurses can initiate contact precautions." Interview further revealed, "The hospital infection control policy applies to the ED." Interview further revealed Patient #13 had a history of MRSA and temperature of 102.8 degrees Fahrenheit and should have been placed on Contact Precautions in the ED. Interview revealed the hospital's isolation policy was not followed.

Interview on 01/25/2012 with the hospital's infection control practitioner revealed, "One of the Infection Control nurses found that (Patient #13) had a history of MRSA when reviewing the Isolation Log on Monday (01/23/2012). She notified the unit to place the patient on Contact Precautions." Interview further revealed Patient #13 should have been placed on Contact Precautions upon presentation to the hospital's ED on 01/19/2012.

2. Medical record review of Patient #14 revealed a 65 year-old who presented to the hospital's ED on 01/19/2012 at 1652 via EMS with altered mental status and pneumonia. Review of the ED record revealed documentation by RN #2 at 1718, "...Isolation Recommended: No...." Record review revealed Patient #14 was admitted to an inpatient unit on 01/20/2012 at 1718. Review of the SBARR ED Admission Report for Patient #14 revealed, "...Pt. Status & Alerts: Isolation: *Standard Precautions...." Review of the electronic medical record for Patient #14 revealed a red exclamation mark (!) in the left upper corner of the screen. Review of the "Alert Description" that opened after clicking on the exclamation mark (!) revealed, "....MRSA Present penis, nares on 06/03/2011. VRE Present urine on 01/24/2009. Place on Contact Precautions with each visit...." Further record review revealed Contact Isolation was ordered by a nurse on 01/23/2012 at 0937 (3 days, 16 hours after presentation to the hospital).

Interview on 01/25/2012 at 0915 with RN #1 revealed the nurse was working in the hospital's ED on 01/19/2012 as the triage nurse. Interview revealed the nurses in the ED do not have access to the computer system that displays alerts for isolation precautions. Interview revealed ED registration personnel have access to the alerts and the nurses depend on the registrars to place blue arm bands on patients that should be isolated. Interview revealed Patient #14 did not have a blue arm band on when triaged. Interview revealed, "If I had known, I would have notified the provider so the doctor could order precautions". Interview further revealed, "Nurses can initiate contact precautions." Interview revealed, "The hospital infection control policy applies to the ED". Interview further revealed Patient #14 had a history of MRSA and VRE and should have been placed on Contact Precautions in the ED. Interview revealed the hospital's isolation policy was not followed.

Interview on 01/25/2012 with the hospital's infection control practitioner revealed, "One of the Infection Control nurses found that (Patient #14) had a history of MRSA when reviewing the Isolation Log on Monday (01/23/2012). She notified the unit to place the patient on Contact Precautions". Interview further revealed Patient #14 should have been placed on Contact Precautions upon presentation to the hospital's ED on 01/19/2012.

3. Medical record review of Patient #12 revealed a 26 year-old who presented to the hospital's ED on 01/18/2012 at 0640 via EMS with altered mental status, chronic renal failure and a history of cryptococcal meningitis. Review of the ED record revealed documentation by RN #3 at 0648, "...Isolation Recommended: Unobtainable due to condition...." Record review revealed Patient #12 was admitted to an inpatient unit on 01/19/2012 at 0044. Review of the SBARR ED Admission Report for Patient #12 revealed, "...Pt. Status & Alerts: Isolation: *Standard Precautions...." Review of the electronic medical record for Patient #14 revealed a red exclamation mark (!) in the left upper corner of the screen. Review of the "Alert Description" that opened after clicking on the exclamation mark (!) revealed, "....VRE Present: Blood on 04/13/2011. Place on Contact Precautions with each visit...." Further record review revealed Contact Isolation was ordered by a nurse on 01/19/2012 at 0140 (19 hours after presentation to the hospital).

RN #3 was not available for interview.

Interview on 01/24/2012 at 1510 with the ED's clinical educator confirmed there is no documentation that a blue arm band was placed on Patient #12 at registration and no documentation that Patient #12 was placed on contact precautions in the ED. Interview revealed Patient #12 should have been placed on contact precautions due to history of VRE.

Interview on 01/25/2012 at 1000 with RN #7 revealed the nurse admitted Patient #12 to the inpatient floor on 01/19/2012 and ordered contact precautions for the patient. Interview further revealed, "Contact precautions should have been initiated in the ED."

4. Medical record review of Patient #20 revealed a 25 year-old who presented to the hospital's ED on 01/20/2012 at 2049 via EMS with paraplegia, anoxic brain injury, back pain and a history of a sacral decubitus ulcer. Review of the ED record revealed documentation by RN #4 at 0648, "...Isolation Recommended: No...." Record review revealed Patient #20 was admitted to an inpatient unit on 01/21/2012 at 2152. Review of the SBARR ED Admission Report for Patient #12 revealed, "...Pt. Status & Alerts: Isolation: *Standard Precautions...." Review of the electronic medical record for Patient #20 revealed a red exclamation mark (!) in the left upper corner of the screen. Review of the "Alert Description" that opened after clicking on the exclamation mark (!) revealed, "....MRSA Present: Buttocks on 08/04/2011. Place on Contact Precautions with each visit...." Further record review revealed Contact Isolation was ordered by a nurse on 01/21/2012 at 2236 (25 hours after presentation to the hospital).

RN #4 was not available for interview.

Interview on 01/25/2012 at 1330 with administrative nursing staff confirmed there is no documentation that a blue arm band was placed on Patient #20 at registration and no documentation that Patient #20 was placed on contact precautions in the ED. Interview confirmed Patient #20 should have been placed on contact precautions due to history of MRSA.










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5. Medical record review on 01/25/2012 for Patient #9 revealed a 26 year-old female that presented to the hospital's ED on 01/18/2012 at 1526 with diabetes and sickle cell crisis. Review of the ED record revealed nursing documentation at 1613, "...Isolation Recommended: No...." Record review revealed the patient was admitted to an inpatient unit (6-South) on 01/19/2012 at 1804. Review of the SBARR ED Admission Report (nursing report from the ED nurse to the inpatient unit nurse) for the patient revealed, "...Pt. Status & Alerts: Isolation: *Standard Precautions...." Review of the electronic medical record for the patient revealed a red exclamation mark (!) in the left upper corner of the screen. Review of the "Alert Description" that opened after clicking on the exclamation mark (!) revealed, "....VRE Present: rectal on 09/15/2011. Place on Contact Precautions with each visit. After 09/15/2012 the patient can be cleared...." Further record review revealed Contact Isolation was ordered by a nurse on 01/20/2012 at 0111 (33 hours after presentation to the hospital).

Interview with the Medical Service Line Director revealed the process for initiating Contact Isolation precautions was for the nursing staff to order Contact Isolation in the computer to request the necessary supplies. Interview revealed the time of the order was the time isolation was initiated. Interview confirmed the first available documentation the patient was placed on Contact Isolation precautions was on 01/20/2012 at 0111 (33 hours after presentation to the hospital). Interview revealed, "(The patient) should have been placed on isolation within a couple of hours of being in the hospital."

6. Medical record review on 01/25/2012 for Patient #10 revealed a 79 year-old female that presented to the hospital's ED on 01/17/2012 at 0812 from a skilled nursing facility with sepsis, urinary tract infection, bilateral lower extremity cellulitis, and renal failure. Review of the ED record revealed nursing documentation at 0830, "...Isolation Recommended: No...." Record review revealed the patient was admitted to the Intensive Care Unit (ICU) on 01/18/2012 at 1312. Review of the SBARR ED Admission Report (nursing report from the ED nurse to the ICU nurse) for the patient revealed, "...Pt. Status & Alerts: Isolation: *Standard Precautions...." Review of the electronic medical record for the patient revealed a red exclamation mark (!) in the left upper corner of the screen. Review of the "Alert Description" that opened after clicking on the exclamation mark (!) revealed, "....VRE Present: RECTAL on 06/02/2008. Place on Contact Precautions with each visit. After 06/02/2009 the patient can be cleared...." Record review revealed Contact Isolation was ordered by an ICU nurse on 01/18/2012 at 1435 (30 hours after presentation to the hospital). Further record review revealed a VRE culture (first one during the admission) was obtained on 01/19/2012 (negative results). Record review revealed the patient was scheduled for a second VRE culture on 01/26/2012.

Interview with the Medical Service Line Director revealed the process for initiating Contact Isolation precautions was for the nursing staff to order Contact Isolation in the computer to request the necessary supplies. Interview revealed the time of the order was the time isolation was initiated. Interview confirmed the first available documentation the patient was placed on Contact Isolation precautions was on 01/18/2012 at 1435 (30 hours after presentation to the hospital). Interview revealed the patient needed to remain on Contact Isolation precautions until 3 successive negative VRE cultures were obtained.





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7. Medical record review on 01/25/2012 for Patient # 21 revealed a 53 year old female who presented to the ED (Emergency Department) on 01/23/2012 at 1735, from her physician's office, for direct admission. Patient #21 presented with Dehydration and vomiting and had with her physician's orders from the office. One of the orders was for a "stool for C.difficile" (Clostridium Difficile). Record review revealed nursing staff acknowledged and signed the order on 01/24/2012 at 0014. Review of ED nursing notes dated 01/23/2012 at 1759 revealed, "...Isolation Recommended : No...." Further review of the ED record shows Patient #21 was either in the waiting room or being reassessed in Triage from 1739 to 2146, at which time she was placed in the "Gateway" section awaiting admission to the floor. Record review shows Patient #21 was discharged from the ED Gateway section to the inpatient unit (2-North) on 01/24/2012 at 0100. Record review revealed the first documentation the patient was placed on Special Enteric Isolation precautions on 01/24/2012 at 1155 (18 hours after she presented to the ED with orders for C. difficile testing).

Interview on 01/25/2012 at 1530 with Patient #21 revealed she had been in the ED around 4 hours, part of that time in the "Gateway" section of the ED, and was never placed on any isolation precautions there.

Interview on 01/26/2012 at 1005 with the Interim ED Director confirmed the patient was not placed on isolation precautions while in the ED (18 hours).

Interview on 01/25/2012 at 1540 with the Nursing administration staff on 2-North revealed when Patient #21 arrived on the floor on 01/24/2012 at 0100 the patient had not been placed on Isolation precautions. Interview confirmed the first available documentation the patient was placed on Isolation precautions was on 01/24/2012 at 1155, (18 hours after she presented to the ED with orders for C. difficile testing).


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