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Based on facility policy review, observation, medical record review, and staff interview, the facility's infection control officer failed to maintain a hospital-wide program for the prevention and control of potential infections by failing to prevent cross-contamination of intravenous prepared medications administered in 1of 2 observed patients receiving intravenous medications (Patient #2), failing to ensure disinfection of a reusable stethoscope between patients in 1of 1 observed patients (Patient #3) having stethoscope used for assessment, failing to ensure soiled laundry was kept in covered container while in the patient treatment area, failing to prevent a patient's urinary catheter bag from being placed on a floor in 1of 1 observed patients with urinary catheters (Patient #4), failed to ensure that 1 of 2 contact isolation patients had isolation signs that were not clear and visible (Patient #1), failed to ensure cleaner/disinfectant spray bottles were labeled with contents and failed to ensure mop water being used for patient room terminal (deep) cleaning was clean.

Findings include:

1. Observation in the facility's Emergency Department (ED) on 10/18/2011 at 1335 revealed registered nurse (RN #1) preparing a bag of "Normal Saline 1000 milliliters) for administration to patient #2 at a counter located directly beside of a hand washing sink. The observation further revealed that the RN was spiking the bag of Normal Saline with intravenous tubing at 1335 when a facility staff member (unidentified by facility) was observed to begin washing his hands. The observation revealed that the unidentified staff member was washing his hands the exact time that the RN was preparing the intravenous medication for administration to patient #2. No barrier or splash guard was noted to separate the staff members. The observation revealed potential cross-contamination of the prepared intravenous medication by RN #1. Observation at 1415 revealed that the RN administered the bag of Normal Saline to patient #2.

An open medical record for patient #2 on 10/18/2011 revealed that the patient presented to the facility's ED for complaint of "Sickle Cell Crisis." The review revealed documentation that the patient received the intravenous bag of Normal Saline from RN #1 on 10/18/2011 at 1415 at a rate of 125 milliliters per hour.

An interview on 10/18/2011 at 1500 with the facility's quality assurance administrative staff revealed that the area of medication preparation should not have anyone performing hand washing at the time of a nurse preparing medications. The interview further revealed that no policy could be found in the facility that discussed cross-contamination prevention for medications.

2. Observation in the facility's Emergency Department (ED) on 10/18/2011 at 1313 revealed registered nurse (RN #2) entering a treatment bay #4 for patient #3 with a stethoscope. The observation revealed that the RN instructed the patient "I need to listen to your heart and lungs." No visualization was able to be done due to a privacy curtain pulled at the time of the ED observation. At 1315, RN #2 was observed leaving the patient's bay and did not clean or disinfect her stethoscope before laying the stethoscope down on her computer terminal area.

An open medical record review for patient #3 on 10/18/2011 revealed that the patient was a 44 year old patient that presented to the ED for a complaint of "nerve problems and anxiety." The review further revealed from RN #2 that she documented the patient's breath sounds (stethoscope used) as "clear bilaterally."

An interview with RN #2 during the observation on 10/18/2011 at 1330 revealed "We should clean our stethoscopes between patient uses with the sanitizer wipes provided."

3. A review of the facility's policy and procedure "Environmental Services Infection Control" (revision date 04/2009) revealed "Linen: Soiled linen shall be bagged, in or near the patient's room and securely closed prior to transport. Soiled linen shall be placed in an impervious bag of sufficient strength to contain wet/soiled linen without contaminating the patient environment."

Observation in the facility's Emergency Department (ED) on 10/18/2011 at 1310 revealed a container full of soiled and dirty linen in the ED hallway with lid not shut and the laundry overflowing from the sides of the container.

An interview during the observation on 10/18/2011 at 1312 with the ED registered nurse #2 revealed that the observed laundry container was the only wet and soiled container for use in the ED.

4. Observation on 10/19/2011 at 1058 in the facility's Medical-Surgical Unit revealed a patient (#4) in her room had a urinary catheter bag with urine present located directly on the floor of the patient's room under her bed. The observation revealed that the facility's nurse (RN #3) was inside of the room as the catheter bag was located on the floor talking to the patient and her family member.

An interview with RN #3 during the observation on 10/19/2011 at 1100 revealed "Oh my that bag should not be on the floor. Let me see if this can be placed right. These beds we have are hard to get the Foley bags to stay without falling.

An open medical record review for patient #4 on 10/19/2011 revealed that the patient was admitted to the hospital on 10/18/2011 with a diagnosis of "Status Post fall and wrist fracture." The review revealed that the patient had an order for the urinary catheter to be inserted for strict intake and output on 10/19/2011. The documentation revealed that the patient received the urinary catheter from the facility's nursing staff on 10/19/2011 at 0900.

5. A review of the facility's policy and procedure "Isolation Guidelines" (Revision date 06/2009) revealed "General Guidelines: Identification of the type of isolation or precaution, including requirements should be taped on the outer door of the patient's room."

Observation on 10/18/2011 at 1410 in the facility's Medical-Surgical Unit revealed that a patient room (patient #1) had a isolation cart located beside of his room with a contact isolation sign on top of the cart under a "sani wipe container." The observation further observed staff members entering the patient's room with isolation personal protective equipment as well. No signs or other information was observed to be on the patient's door to indicate that the patient room was a contact isolation room.

An interview on 10/18/2011 at 1420 with the nurse assigned to patient #1 revealed "The patient is on contact isolation precautions. He should have signs on the door."





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6. Observation on 10/19/2011 from 1240-1250 of environmental services (EVS) staff cleaning a room of a discharged patient (ICU #5). Observation revealed two unlabeled spray bottles containing colored fluid being used by the EVS staff to clean/disinfect surfaces in the room.

Interview during the observation with the EVS director revealed the spray bottles contained different cleaner/disinfectants used in the hospital. Interview revealed the EVS staff dispense each cleaner/disinfectant from a automatic dispenser into the individual spray bottles. Interview revealed the spray bottles should be labeled with a manufacturer's label indicating the contents. Interview revealed there was no way to identify the contents of the bottles currently being used by the staff to clean ICU #5. Interview revealed "the containers should be labeled."

7. Review on 10/19/2011 of facility procedure "Deep Room Cleaning" (no date) revealed "Change the mop water every 2-3 rooms or as needed.

Observation on 10/19/2011 from 1240-1250 of environmental services (EVS) staff cleaning a room of a discharged patient (ICU #5). Observation revealed the mop water on the cart in service was dirty. Interview with EVS staff during the observation revealed the mop water had been used to clean a room just prior to the staff cleaning ICU #5.

Interview with the EVS director during the observation revealed the mop water should have been changed prior to cleaning ICU #5.

Based on review of the facility infection control log and staff interview infection control staff failed to include in the infection control log those patients meeting criteria for isolation precautions.

Findings include:

Review on 10/18/2011 of the facility's infection control log revealed no documentation of any patient's requiring isolation precautions higher than standard precautions (routine infection control precautions).

Interview on 10/18/2011 at 1350 with the facility's infection control officer revealed patient's who meet criteria for isolation precautions other than standard precautions are not logged into the infection control log. Interview revealed "I didn't realize we needed to do that." Interview revealed no further evidence of tracking incidents into a log of patient's meeting criteria for isolation precautions.

NC00076109