HospitalInspections.org

Based on the nature of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.42, INFECTION CONTROL, was out of compliance.

A-0749 - Standard: The infection control officer or officers must develop a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel. - The facility failed to maintain appropriate infection control processes in the areas of pest control, facility maintenance, monitoring of filtration systems, and dressing changes for peripheral intravenous central catheters (PICC). These failures created the potential for transmission of health care acquired infections to patients receiving care in the facility.

Based on observation, interviews and document review, the facility failed to maintain appropriate infection control processes in the areas of pest control, facility maintenance, monitoring of filtration systems, and dressing changes for peripheral intravenous central catheters (PICC).

These failures created the potential for transmission of health care acquired infections to patients receiving care in the facility.

FINDINGS:

POLICY

According to the policy, General Infection Prevention Policy, staff will communicate and collaborate with the Infection Preventionist in identifying and resolving infection issues related to patient care.

According to the policy, Health Infection Prevention Plan, Infection Prevention Preventionists serve in an advisory/consultative role to all areas and staff.

According to the policy, Intravenous Therapy: Central Venous Catheter (CVC) and Peripherally Inserted Central Catheter (PICC) Practice Guideline for Nursing and Allied Health Professionals, transparent dressings, including those where antimicrobial-impregnated patches are used, are changed every seven (7) days; when compromised or soiled; or as directed by physician.

REFERENCE

According to the Association of Operating Room Nurses (AORN), Guidelines for Perioperative Practice, 2015:

Recommendation IV.g. and IV.g.1. (page 276), The direction of the airflow from one room to the adjacent area is designed and engineered to minimize the flow of contaminates from clean to less-clean areas. Disruptions in the airflow patterns within the OR can redirect contaminants onto the sterile field. The restricted area should have a positive pressure relationship to the adjacent areas.

Recommendation IV.i.1 (page 277), Doors to the operating or invasive procedure room should be kept closed except during the entry and exit of patients and personnel. When the doors are left open, the HVAC system is unable to maintain critical environmental control parameters. Leaving the door open can disrupt pressurization. The ventilation system in the OR is designed to administer air pressure that is greater than the pressure in the semi restricted area.

Recommendation IV .i (page 277), Preventative maintenance, including regular inspection and changing of filters, should be performed on HVAC systems. A properly functioning HVAC system minimizes the risk of contamination to the sterile field and is an essential component in SSI prevention. The filter should be changed according to the manufacturer's instruction for use because as the air filter ages, its effectiveness decreases.

1. The facility did not ensure preventative actions were implemented after staff observations of insects were noted in the Operating Rooms (OR) and areas located directly outside of the ORs.

a) On 11/10/15 at 1:17 p.m., a tour of the surgical department was conducted with the OR Manager (Registered Nurse #1, RN). During the tour, the following insects were noted:

At 2:52 p.m., two living flies were observed flying toward the light fixture in OR #3. Two Maintenance Specialists were observed operating a vacuum cleaner in an attempt to catch the flies. One of the Maintenance Specialists (Employee #2) stated s/he vacuumed flies from the light fixtures in the ORs every few months.

At 3:10 p.m., one living fly was observed in Substerile Room B, which was located between OR #1 and OR #2.

At 3:15 p.m., one living fly was observed flying toward the light fixture in OR #2. An Environmental Services staff member (Employee #3) was cleaning the room during the observation and stated s/he felt the issue of bugs in the surgical department was not too bad and that employees in the plant operations department were responsible for cleaning up insects.

b) On 11/11/15 at 1:54 p.m., a review of facility work orders generated from staff revealed an order dated 10/26/15. The order stated, "Is there anything we can do about the living and dead flies up in the fluorescent lights in all the ORs? Most of them are dead, but once in a while you see one move. It looks very bad! MD (Medical Doctor) noticed and not happy."

c) On 11/12/15 at 10:41 a.m., an interview with RN #5 was conducted. RN #5 stated s/he saw a fly in the hallway to the ORs earlier in the week and swatted it with a box of surgical hats, then discarded the box. RN #5 further stated s/he did not recall seeing additional flies in the ORs in the past, however, s/he did recall seeing dark spots inside the light fixtures.

On 11/11/15 at 12:17 p.m., an interview with the OR Manager (RN #1) was conducted. RN #1 stated beginning in early September s/he had seen flies in the OR hallways and in the light fixtures of the ORs. RN #1 further stated s/he had recently issued a work order regarding the presence of flies in the ORs, however s/he was unaware of anything being done to prevent the occurrence of flies.

On 11/12/15 at 8:13 a.m. and 12:09 p.m., an interview with the RN Infection Preventionist (RN #4) was conducted. RN #4 stated s/he was responsible for overseeing infection control procedures in the surgical department. RN #4 stated s/he was unaware of the presence of flies in the ORs and there was a disconnect in communication with the surgical department alerting RN #4 of infection control issues. RN #4 stated the presence of flies in the ORs could spread infection and s/he expected the issue would have been brought to his/her attention.

On 11/11/15 at 2:57 p.m., an interview with the Chief Executive Officer (CEO) was conducted. The CEO stated s/he had been employed with the facility for approximately three months and was acting as an interim Facility Operations Senior Manager, which involved being responsible for overseeing the facility's plant operations department and handling pest control issues. The CEO stated upon hire s/he had been alerted by staff about the observation of flies in the light fixtures in the facility. The CEO further stated s/he was unaware of the work order dated 10/26/15 regarding flies observed in the ORs. The CEO added that other than vacuuming up or swatting flies each time they were observed, s/he was not aware of any preventative measures being taken to attempt to decrease the presence of flies in the ORs.

2. The facility did not ensure positive pressure was continuously maintained in OR #1.

a) On 11/10/15 at 2:28 p.m., a tour of OR #1 was conducted with the OR Manager (RN #1). The swinging door located between OR #1 and the sub sterile room was observed to be opened approximately 2 inches. RN #1 stated s/he became aware of the door being stuck opened about 3 weeks ago and s/he had alerted the Facility Operations Senior Manager at that time. RN #1 stated the crack in the door appeared to have gotten worse since s/he first noted the issue.

b) On 11/11/15 at 9:14 a.m., an interview with a Maintenance Specialist (Employee #6) was conducted. Employee #6 stated the first time s/he was made aware of the malfunctioning door between OR #1 and the sub sterile room was earlier in the morning on 11/11/15. Employee #6 stated s/he noticed the door was cracked open and stated they should have met up in the middle of the frame. Employee #6 further stated s/he was unable to fix the door and further research was needed to find the cause of the malfunction.

On 11/12/15 at 8:13 a.m. and at 12:19 p.m., an interview with the RN Infection Preventionist (RN #4) was conducted. RN #4 stated the facility followed national infection control guidelines from the Centers for Disease Control and Prevention (CDC) and the Association of Operating Room Nurses (AORN). RN #4 stated s/he was unaware of the issue of the door between OR #1 and the sub sterile room being cracked open. RN #4 further stated it was important that doors to the ORs remain closed in order to ensure positive pressure in the room to help decrease infection, however s/he was unaware of guidelines from AORN or the CDC regarding air pressure in ORs.

On 11/11/15 at 2:57 p.m., an interview with the Chief Executive Officer (CEO) was conducted. The CEO stated s/he had been employed with the facility for approximately three months and was acting as an interim Facility Operations Senior Manager, which involved being responsible for overseeing the facility's plant operations department. The CEO stated s/he was not aware of the issue with the open door located between OR #1 and the sub sterile room until the morning of 11/11/15. The CEO further stated doors to the ORs needed to be closed in order to reduce the risk of infection and that surgery should not occur in that room until the door was fixed.

3. The facility did not ensure routine inspection and changing of air filters was performed on the facility's HVAC system according to manufacturer's guidelines.

a) On 11/12/15 at 11:08 a.m., an interview with the Maintenance Specialist (Employee #6) was conducted. Employee #6 stated the facility did not keep a log of when air filters were changed. Employee #6 provided a printout from the air filter manufacturer's website and stated it was the manufacturer's guidelines for the air filter they used in the facility's HVAC system. Employee #6 reported the printout listed the Final Resistance level at 1.5" but the facility would change the air filters when the Final Resistance level reached 2" (final resistance is measured on a dirty filter and will have an impact on efficiency and dust-holding capacity). Employee #6 stated s/he did not know what the term Final Resistance meant or if the air filters should have been changed at the level of 1.5". Employee #6 further stated the facility had always changed the filters at a Final Resistance level of 2" and had received guidance to do so from an employee from the HVAC system company.

b) On 11/12/15 at 8:13 a.m. and at 12:19 p.m., an interview with the RN Infection Preventionist (RN #4) was conducted. RN #4 stated the importance of having effective air filters in the ORs involved bringing clean air into the ORs and preventing infection. RN #4 further stated s/he was unaware of the manufacture's guidelines on when to change the air filters, but stated the plant operations department was responsible for changing them and s/he expected they would be changed according to manufacturer's instructions.

c) On 11/11/15 at 2:57 p.m., an interview with the Chief Executive Officer (CEO) was conducted. The CEO stated s/he had been employed with the facility for approximately three months and was acting as an interim Facility Operations Senior Manager, which involved being responsible for overseeing the facility's plant operations department. The CEO stated s/he was not aware of the manufacturer's guidance on when air filters were to be changed. The CEO further stated s/he was not aware of the facility's process for monitoring the effectiveness or the changing of the facility's air filters.

4. The facility did not ensure maintenance on soiled ceiling tiles located adjacent to the ORs was performed.

a) On 11/10/15 at 2:37 p.m. a tour of sub sterile room A with the OR Manager (RN #1) revealed a light tan discoloration on the ceiling tile located directly above an autoclave.

b) On 11/11/15 at 12:17 p.m., an interview with RN #1 was conducted. RN #1 provided a work order dated 10/06/15 of items that needed to be repaired in the surgical department. The work order stated tiles in subroom A had steam damage and needed replacing. RN #1 stated s/he wanted the soiled ceiling tiles repaired due to infection control and possible mold.

On 11/12/15 at 8:13 a.m. and at 12:19 p.m., an interview with the RN Infection Preventionist (RN #4) was conducted. RN #4 stated s/he performed infection control monthly rounds throughout the facility, however, s/he had never noticed stained ceiling tiles above the autoclave. RN #4 stated a potential concern with stained ceiling tiles was that if moisture was the cause of the stain, the tiles could breed bacteria and mold. RN #4 stated s/he would have expected the ceiling tiles to be fixed sooner from a work order dated 10/06/15.

On 11/11/15 at 2:57 p.m., an interview with the Chief Executive Officer (CEO) was conducted. The CEO stated s/he had been employed with the facility for approximately three months and was acting as an interim Facility Operations Senior Manager, which involved being responsible for overseeing the facility's plant operations department. The CEO stated s/he was not aware of the work order dated 10/06/15 regarding the stained ceiling tiles located above the autoclave. The CEO further stated the tiles should have been addressed because of potential mold issues and fire safety.

5. The facility did not ensure peripheral intravenous central catheter (PICC) dressings were changed in accordance with facility policy.

a) On 11/10/15 at 2:15 p.m., a tour of the Medical Surgical Unit was conducted which revealed Patient #10 had a PICC. RN #7 was unable to state when Patient #10's PICC dressing was last changed. RN #7 reviewed Patient #10's electronic medical record and could not find evidence showing the date the dressing was last changed, or when the PICC was placed. RN #7 stated the PICC was present upon the patient's admission.

RN #7 was observed assessing Patient #10's PICC dressing. The dressing appeared to be lifted at the edges and a date of 11/02/15 was written on the dressing. RN #7 stated the non-intact dressing was a new finding and had probably occurred when Patient #10 had showered that morning. RN #7 stated PICC dressings should be changed every seven days or as needed. RN #7 further stated Patient #10's PICC dressing should have been changed the day before (11/09/15), which would have been seven days after the written date of 11/02/15 on the dressing. RN #7 stated s/he did not look at the date on dressing when Patient #10 was assessed earlier that morning. RN #7 further stated s/he did not usually look for the date.

b) On 11/12/15 at 8:13 a.m. an interview with the RN Infection Preventionist (RN #4) was conducted. RN #4 stated the expectation for the frequency of PICC dressing changes was every seven days if the dressing was occlusive and sooner if it was a gauze dressing. RN #4 stated s/he would have expected the PICC dressing on Patient #10 to have been changed on the date the dressing change was due.