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Based on record review, document review, policy review, observations and staff interview, the facility failed to ensure the effective implementation of and compliance with infection control measures for two (#5, #6) of ten sampled patients and failed to maintain a sanitary environment for two patient rooms.

Findings include:

1. Patient #5 was admitted on 7/27/15 with a foot ulcer. Patient #5 was administered Vancomycin 1 gram intravenously on 7/27/15 at 3:33 p.m. as ordered by the Emergency Department (ED) physician. Patient #5 was seen in consultation by an Infectious Disease physician who ordered a culture of the foot ulcer on 7/28/15 at 11:43 a.m. The culture sample was collected on 7/28/15 at 4:00 p.m. The final results of the culture were dated 7/31/15 at 12:05 p.m. The results were reported as two infectious organisms (pseudomonas and methcillin sensitive staph aureus-MSSA) that were not sensitive to treatment with Vancomycin. The Daily Antibiotic Stewardship report dated 8/6/15 included documentation of the laboratory culture results dated 7/31/15 at 12:05 p.m. The documentation indicated the pharmacist reviewed the culture report on 8/3/15 and called the attending physician with recommendations to add an antibiotic that would be effective in treating the identified organisms. The physician order to begin administering an additional antibiotic was signed by the attending physician on 8/4/15. On 8/5/15 the Infectious Disease physician wrote an order to discontinue the antibiotic ordered by the attending physician and begin administering the antibiotic recommended by the pharmacist to treat the identified infectious organisms in the foot wound.

The Antimicrobial Stewardship Program, policy #MM 0.011, last review date 5/15, was reviewed on 8/6/15. Page 2, C. indicated a report on patients on Antimicrobial treatment is generated daily. Page 2, D. indicated the Antimicrobial report will be reviewed daily by a pharmacist and acted upon as described in pharmacy policies. Page 3, 5 indicated the policies included determining the appropriate Antimicrobial based on the culture results.

An interview and record review was conducted with the Vice President of Quality and the Pharmacy Clinical Coordinator on 8/6/15 at approximately 3:30 p.m. They confirmed the finding Patient #5 did not receive appropriate Antimicrobial therapy for the infection until 5 days following the final results of the culture and sensitivity report and 8 days following his admission. They confirmed the finding the 3 day interval between the results of the wound culture being reported and the pharmacist's recommendation to the attending physician was not in compliance with the facility policy.

2. Observations were conducted of patient room 204 and 209 on the 2 Progressive Care Unit (PCU) at the time of the tour on 8/6/15 at approximately 1:15 p.m. Both rooms were observed to have 35 gallon waste containers overflowing with discarded personal protective equipment (PPE) to the point the covers of the containers remained open 4-6 inches and the used PPE was hanging over the outside walls of the containers. The Vice President of Quality and the Director of the unit were present at the time of the observations and confirmed the finding.

3. Patient #6 was admitted on 8/5/15 at 8:32 a.m. to room 204 with a diagnosis of herpes zoster (shingles). The History and Physical dated 8/5/15 at 4:52 p.m. and signed by the attending physician indicated the treatment plan included contact isolation precautions.

The Nursing Admission Assessment dated 8/5/15 at 7:29 p.m. and signed by the Registered Nurse (RN) included documentation Patient #6 was on droplet isolation precautions. The shift assessment dated 8/6/15 at 12:30 p.m. and signed by the RN included documentation Patient #6 was on contact and droplet precaution isolation.

The document Negative Pressure Room Monitoring was reviewed on 8/7/15. The review of the document failed to reveal documentation of the monitoring of Room 204 on 8/5/15 or 8/6/15. Room 204 was documented to have negative pressure on 7/27/15 and 8/7/15.

Observations conducted at the time of the tour on 8/6/15 at approximately 1:15 p.m. included an 8 1/2" x 11" post card attached to the door frame of room 204 indicating Patient #6 was in airborne precaution isolation.

Isolation Precautions, Policy #6.2, revised 10/14 was reviewed on 8/7/15. Page 4., 8.2. Airborne Precautions, c. Measles and Varicella indicated a private negative airflow room was required.

TB Control Plan, Policy #8, revised 8/14 was reviewed on 8/7/15. Page 6. 1. included room 204 was one of several negative pressure rooms in the facility that conform to Centers for Disease Control (CDC) guidelines. Page 6. 2. indicated negative pressure rooms were to be monitored daily by the nursing supervisor when the room was in use, and documented in a logbook.

An interview and record review was conducted on 8/7/15 at approximately 11:00 a.m. with the Director of Quality Management. In response to questions, he indicated the implementation of isolation precautions was part of the nursing plan of care and did not require a physician's order. He confirmed the finding Patient #6 was not placed in appropriate isolation precautions for the diagnosis until more than 24 hours following admission to the facility.

An interview and document review was conducted on 8/7/15 at approximately 11:15 a.m. with the Nursing Supervisor. The Nursing Supervisor confirmed his signature appeared on the log indicating the negative pressure in room 204 was documented on 7/27/15 and 8/7/15. He confirmed the finding room 204 was in use and was not monitored in compliance with facility policy on 8/5/15 and 8/6/15.

Based on policy review and staff interview, the facility failed to ensure three of three interviewed Registered Nurses (RNs) of a total staff of 5 RNs in the Intensive Care Unit (ICU) were appropriately trained regarding cleaning the point of care glucose monitoring devices.

Findings include:

The ICU RN Charge Nurse and two ICU RN staff nurses were each interviewed separately regarding the cleaning procedure for the point of care finger stick glucose device at the time of the tour of the ICU on 8/7/15 at approximately 9:45 a.m. None of the three interviewed RNs were able to describe the procedure.

The review of the policy "POCT Nova Statstrip Glucose Meter" no policy number indicated, revised 2/2015, VII. Maintenance indicated the meter should be cleaned with a cloth that had been dampened with a 10% bleach solution or a Sani Cloth disinfectant wipe. All cleaning residue should be removed immediately with a water-dampened cloth. The device should be dried thoroughly with a soft cloth or lint free tissue.

The Nurse Manager of the ICU was present at the time of the interviews and confirmed the finding that none of the three interviewed RNs were informed of the correct cleaning procedure for the device.