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Based on review of clinical records and facility documentation and staff interviews it was determined the facility failed to ensure the identification, reporting, investigation and controlling of pest in the facility. This practice may cause the pest to spread throughout the facility and bites from the pest to become infected.

Findings include:

Record review revealed a patient was admitted from the Emergency Department (ED) on 6/13/12 for a cardiac condition. Patient #1 was scheduled for a Coronary Artery Bypass Graft on 6/28/12. On 6/13/12 the patient was transferred from outpatient observation and admitted to inpatient room (semi private). On 6/18/12 the patient was transferred to a private room. On 6/19/12 the patient went to the Cardiac Catheterization Department and the Radiology Department for procedures prior to being transferred to a semi private. Review of documentation did not reveal evidence as to why the room changes occurred. Review of the Infectious Disease Consult dated 6/21/12, eight day after admission, revealed on admission the patient had swollen legs and redness especially on the calves. The documentation revealed the patient stated he had bed bug bites that exacerbated the situation by prompting him to scratch the lesions. Review of the record revealed no further documentation of bed bug bites or an assessment of the area from the nursing staff. Review of facility documentation dated 6/28/12 revealed at 5:30 a.m. a Patient Care Technician (PCT) noticed a bed bug on the patient's gown as he was being prepped for surgery. Review of the documentation revealed upon further investigation live bed bugs were noted on the floor and the surgery department was informed. The Physician Assistant (PA) requested the patient's gown be placed in ziploc bag and a specimen cup with the bed bugs be sent with the patient to the Operating Room (OR) holding room. The documentation noted the (Infection Prevention) IP nurse was notified. The IP nurse and Environmental Services positively identified the bed bugs. Interview with the Infection Prevention (IP) nurse on 7/2/12 and 7/3/12 revealed she was not notified of the bed bug bites and did not become aware of the bed bugs issue until 6/28/12 when a PCT reported bed bugs on a patient. The interview revealed the PCT reported the bed bugs on 6/28/12 at 5:230 a.m. when providing a pre surgical bath prior to cardiac surgery. Interview with the IP nurse revealed she disagreed with sending the specimen and clothing to the OR. She informed the OR staff not to open the bags. Interview revealed the IP nurse was not aware of where the specimens were sent after the OR. Interview with the Clinical Manager of Cardiac Step-down Unit on 7/2/12 at approximately 1:15 p.m. revealed the patient was bathed and a clean gown and linens were provided after the bed bugs were identified. She stated the bed bugs were placed in a specimen contained and the patient's gown was placed in a sealed bag. The PA was notified of the bed bugs findings. The PA ordered the specimen container and gown to be sent to the Operating Room (OR) with the patient for inspection by the cardiac surgeon. The order was carried out by the nursing staff. Review of nursing documentation revealed no documentation related to the identification of bed bugs or bathing and linen changes. Record review revealed no documentation of the linen being bagged or the specimen being sent to the OR as ordered by the PA. The cardiac surgeon canceled the case. Interview with the Clinical Manager on 7/2/12 at 1:15 p.m. confirmed the above findings. Interview with the Surgery Assistant who transported the patient to the holding room of the OR revealed he saw 2 live bed bugs on the floor of the patient's room and killed them. Interview with the circulating nurse caring for the patient revealed the patient was in the holding room for approximately 45 minutes with the specimens in sealed bags and was told the patient was cleared of bed bugs by the IP nurse. The patient's gown and bedding were clean and it was safe to transport him to the OR. Interview revealed she did not take the specimens out of the holding room. The nurse was not aware of where the bags were sent. Interview revealed once the surgery was canceled, the circulating nurse washed the patient from head to toe and a clean gown and linens were provided. There was no documentation in the OR nursing record of bathing the patient in the OR. Interview with the OR Manager on 7/3/12 at 11:15 a.m. revealed she did not see the bed bug specimens. She was not aware of where they were sent from the holding room. The interview revealed the staff was instructed not to enter OR #8 until after it was cleaned by Environmental Services. A perfusionist entered the room after the patient left OR #8 to run a test on equipment. Review of the Infection Control log for the month of June 2012 revealed on 6/19/12 a RN reported a bed bug in the PCU-A staff lounge. The pest was captured and positively identified as bed bug. Interview with the Infection Prevention (IP) nurse on 7/3/12 at 8:30 a.m. revealed environmental services was called. Review of the Environmental Services Pest Sighting log revealed no entry on 6/19/12. Review of patient #1's nursing notes revealed the RN who reported the bed bug in the staff lounge on 6/19/12 was the same RN who was providing care to the patient. Interview with the Director of Environmental Services confirmed there was no entry in the Pest Sighting log on 6/19/12. The interview confirmed the lack of documentation that the pest company service summary did not specify that the PCU staff lounge was treated. The Director stated that a department supervisor accompanied the exterminator who was onsite doing a routine pest service for the facility to the PCU lounge but wrote CCU lounge on the paper. Interviews with the IP nurse and the Director of Environmental Services revealed they felt this was an isolated incident and no further rooms were inspected for bedbugs. Review of the Pest Control Policy #33 last revised 5/2009 revealed the housekeeping supervisor will log all pest control complaints, notify the pest control company immediately and will accompany the pest control technician on treatment rounds. Interview with the IP nurse on 7/3/12 at 2:25 p.m. revealed she was responsible to perform the bed bug investigation. Interview revealed she could not remember who the nurse was who reported the bed bugs in the staff lounge. She was not aware that it was the same nurse caring for the patient with bed bugs. No other rooms or patients were inspected. Interview revealed she was not aware the Infection Disease physician's consult revealed bed bug bites. The IP nurse was not aware the transporter saw live bed bugs or who the transporter was. Interview revealed the immediate action was related to surgery and the rooms where the patient stayed previously. The chart was not reviewed to determine other departments that could have been affected such as the cardiac catheterization and radiology department. Interview revealed that although patient rooms where the patient previously stayed were evacuated, inspected and treated on 6/28/12, the Cardiac Catheterization Laboratory and Radiology were not inspected. Interview revealed there was no process in place to ask about bed bugs or policies for bed bugs. Review of documentation with the Director of Risk Management revealed there were no entries for bed bugs in the month of June. The interview and review of documentation did not reveal evidence the facility identified the bed bugs in a timely manner, investigated where the patient had been for possible contamination with the bed bugs, OR standards were maintained, the location of the contaminated gown and specimens had been located, or ensure an action was developed.