HospitalInspections.org

Based on record review, policy review, document review and interviews the hospital failed to ensure staff reported concerns with violation of the infection control policies used to prevent and control the transmission of infections within the hospital to their internal safety reporting system for 1 of 4 patient (Patient 1) and his visitors. This deficient practice has the potential to place patients, visitors and staff at risk for contracting an infectious disease.


Findings Include:


Review of the facility policy titled; "Standard and Transmission Based Isolation Policy" approved 08/2022 showed, "POLICY" ...Patient transport only when medically necessary and if the patient does transport cover and contain all draining wounds, cover patient with clean flat sheet, ... Patient's ambulation outside of their room may not leave their room but when ambulating outside of their rooms the patient should don a clean patient gown or clothing, hand washing and limit contact with the environment. A surgical mask should be worn if the patient has an illness requiring Droplet or Contact and Droplet precautions. Ambulating patients may not leave their rooms when they have: Illnesses requiring Airborne Precautions. Visitors are advised to wear appropriate PPE while in the presence of the patient with known or suspected conditions requiring isolation. The PPE for family and visitors Airborne and Contact Precautions are wear a gown, a surgical mask, and gloves while visiting. Please wash your hands or use hand sanitizer when entering and exiting the room."

Review of the facility policy titled; "Incident/Event Reporting" approved 10/2021 showed " ... ... POLICY ...

... II. Immediate Report. An Incident/event that may represent a significant variation from procedures/policy/protocol or breach in the standard of care, and/or may be related to an unanticipated death, serious physical or psychological injury or major permanent loss of function of risk thereof, not related to the natural course of the patient's illness or underlying condition will undergo a focused investigation, follow up, and analysis and appropriate corrective action as described in the Adverse/Sentinel Event policy. Report these events immediately by paging Risk Management on call and/or NAC/administrator on call ...

...V. Reporting process

A. General

1. Confidential Event Report. The event report should be initiated as soon as possible using the event reporting system. Hospital Risk Management must be informed within 24 hours of the incident/event. Confidential information in addition to the information recorded on the confidential event report may be communicated by contacting Hospital Risk Management at extension 588-7468.
... ...
7. Confidential event reports are routed to Risk Management, appropriate managers and staff designated to conduct preliminary peer review. Initial investigation, follow up and preliminary standard of care determination, including clinically justifiable rationale, are to be completed by the manager or designee within 5 business days of the initial report.

VI. Incident/Event investigation

A. Risk Management will review, analyze, and investigate events reported. Trends or patterns will be reported to the appropriate peer review or performance improvement committee and/or department. ..."

Patient 1

Review of Patient 1's medical record showed Patient 1 admitted on 09/07/22 with chief complaint of a skin rash with painful papules for 4 days. The admitting diagnosis is skin rash with painful papules, fever, bilateral tender inguinal lymphadenopathy (swollen lymph nodes in the groin area), transient Transaminitis (high levels of an enzyme called transaminase). Past Medical History of abscess on left buttocks with a surgical history of an appendectomy. The patient was placed in contact/airborne with eye protection isolation on 09/07/22 at 7:23 PM. Infectious Disease consult on 09/07/22 at 9:45 PM Skin assessment: genital/penile ulcers with satellite lesions (hands/palms, scalp), secondary to Monkeypox virus, painful bilateral inguinal lymphadenopathy, Pustular (pus filled), pruritic (itch) eruptions are appearing on various locations of the body (finger, back, buttocks, head). The comprehensive care plan entered for patient is Risk for Infection with a goal for knowledge of infection control procedures. Patient 1 discharged on 09/16/22 to home with family support.

Review of Staff K, Infection Preventionist (IP) registered Nurse (RN) progress notes on 09/07/22 at 7:22 PM showed: ..."Transport: Movement of the patient outside of the room should be limited to medically essential purposed. If the patient is transported outside of their room, they should use well-fitting surgical mask, clean linens and gown and have any exposed skin lesions covered."

Review of Staff O, Registered Nurse (RN), nursing progress note documentation on 09/09/22 at 8:01 AM showed: "Pt call light on, states "going outside to smoke" Attempt to convince him to stay as I was bringing him his NicoDerm patch, but he said he didn't want it, he was irritated he was going outside to smoke and would be right back."


Review of Physician Progress note dated 09/11/22 at 8:13 AM, by Staff P showed: "He had a poor night. He has been walking out of the room, which has been causing some difficulty among the unit. However, he explained that he has been getting out as he's been upset that he hasn't been getting his food at a timely manner, difficulty with pain management, stepping out to try to catch staff's attention. Yesterday, he did get very upset and left the unit to smoke.

During an interview on 09/19/22 at 2:39 PM Staff I, Patient Care Technician (PCT) stated that last week Patient 1 and his visitor who were not being compliant with their isolation PPE and masks. She stated the patient, and his friend did not want to stay in the room.


During an interview on 09/19/22 at 2:55 PM staff J, Unit Secretary stated that last week there were family members of Patient 1 who were not following isolation protocols and they had to call upper management to come to the floor and speak with Patient 1's family members. She further stated that Patient 1's visitors did not use the alcohol-based hand sanitizer when leaving the room.


During an interview on 09/20/22 at 10:14 PM Staff D, Nurse Manager stated that she was not aware of infection control issues with Patient 1 and his visitors last week in "live time" but that she is aware this week. When asked if an incident report was completed, Staff D stated she had not seen one. She further stated that the process for capturing any patient or visitor noncompliance with infection protocols would be to complete a Safety Intelligence Reporting Event (SI) and that doing so would send an alert to the Nurse Manager and Nurse Educator of the unit. When asked if an SI was completed, she stated "not to my knowledge." Staff D stated that Patient 1 was off the unit on 09/15/22 for approximately 35 minutes, and they were unsure where Patient 1 was at that time. She stated that someone was able to contact him on his cell phone and he returned to the unit.


Review of the Incident Report for the month of 09/2022 failed to show any incident involving Patient 1 or his visitors breaches in the policy called "Standards and Transmission Based Policy," and hospital staff failed to complete safety intelligence reporting event (SI) capturing Patient 1 and his visitors noncompliance with infection control protocols.


During an interview on 09/20/22 at 11:28 AM, the Infection Prevention and Control (IPAC) team confirmed that they were only notified about the incident that occurred on 09/09/22 concerning Patient 1 and his visitors not following infection control protocol. Staff B RN, IPAC Supervisor stated that if a patient continued to be non-compliant with isolation precaution, then the next step would be to escalate the complaint to risk management and or if necessary, they could have a complex behavioral health patient conference.