HospitalInspections.org

Based on observation and staff interview, the facility failed to implement infection control practices by not (1) Performing handwashing before entering, and after leaving a patient's (#1) room who was on contact isolation for Clostridium Difficile (C-Diff); (2) Failed to wear Protective Personal Equipment (PPE) for Patient #2 on contact precautions for 2 of 2 observations (Employees D, E, F); (3) Failed to leave multi-dose vials of insulin outside patients' rooms for 2 observations ( Employees K, G), to prevent cross-contamination.


The findings include:


1. During the initial tour of the facility on 4/24/18 at 10:35 a.m., Employee A was observed exiting Patient #1's room with a gown and gloves in her hand. A sign was observed outside patient's door for Contact Precautions (Room #4110). Surveyor observed Employee A did not perform handwashing measures before and after leaving the room.


An interview was conducted with Employee A on 4/24/18 at 10:50 a.m., at which time she stated, "I did not see a trash can by the door, so I did not throw out the PPE." She explained that she threw it out in the trash by the Nurses' station and washed her hands afterward. Employee A stated, "I was changing the patient's diaper. He is incontinent. He had a soft bowel movement."


A review of Patient #1's medical record revealed a laboratory report dated 4/11/18 indicating the patient had a positive test result for C. Difficile. A review of the Physician's Orders dated 4/11/18 revealed Isolation Precautions related to C. Difficile.


Observation made on 4/25/18 at 9:45 a.m. Sampled Patient #1 was observed in the room; a sign that patient was on Contact Precautions was observed. Employee E (ARNP) and Employee D (MD) were observed inside the room without wearing complete Personal Protective Equipment (PPE) gown and gloves. Employee D and Employee E had worn only gloves. Surveyor asked what purpose the sign was for, and Employee E responded, "We don't need to wear a gown, because the patient is not having loose stool."


On 4/25/18 at 10 a.m., Employee D stated that she will correct this by discontinuing the order for contact isolation.


Interview conducted with the Nurse (Employee B) caring for Patient #1 on 4/25/18 at 10:00 a.m. She stated,
"Patient # 1 is on Contact Isolation Precautions for infectious C-Diff. If you are following protocol, you have to gown and glove when going in to the patient's room and wash your hands with soap and water because it's C-Diff."


(2) The next room observed on 4/25/18 at 10:10 a.m., Surveyor observed signage outside patient's door for Contact Precautions for Room #4111 (Patient #2). There were Personal Protective Equipment and supplies available on the patient's door. Employee F (Nurse Practitioner) was observed entering the patient's room without wearing the necessary Personal Protective Equipment. She was observed at bedside talking with the patient.


Interview conducted with the Nurse caring for Patient #2 (Employee B) on 4/25/18 at 10:10 a.m. She stated,
"Patient #2 is on Contact Isolation Precautions for infectious ESBL in the urine. You have to gown and glove when going into the patient's room." She confirmed Employee F was observed not using PPE when entering the room and she provided PPE inside for Employee F to don.


Interview conducted with Employee F on 4/25/18 at 10:20 a.m. She stated, "Patient #2 is on Contact Isolation Precautions". She explained that initially, she did not see the signage outside patient's door for Contact Precautions. Stated, "I forgot to don PPE."


An interview with the Charge Nurse on 4/25/18 at 1:55p.m. confirmed that patients (Patient #1 and Patient #2) in Room 4111 and Room 4110 were on Contact Isolation. This was also confirmed through Surveyor's review of Physician's orders. Upon further clarification, the Unit Charge Nurse agreed and stated that expectations were for the MD and ARNP to set a good example for direct care staff and follow the contact precautions by wearing complete PPE gown and gloves. She explained all staff were expected to follow the hospital's infection control policy.


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3. (a) During a tour of the facility on 4/24/2018 at 12:37 a.m., an observation was made of Employee K, RN exiting a room with a vial of insulin on her portable workstation. She was interviewed at this time and stated that she took the insulin (Multi-dose) vial into each patient's room to draw up, administer, and sign off on the administration of the medication for each patient. She stated that she has always done this.


An interview was conducted with Employee L, RN Manager on 4/24/2018 at 12:56 p.m. after speaking with Employee K; Employee L, RN Manager stated that the facility did not prevent staff from bringing the insulin vials into the direct patient care area/rooms for administration; she supported that staff needed to scan the insulin vial at the bedside.


(b) Employee G, RN was observed for Medication Pass for Patient #5 on 4/24/2018 at12:57 p.m. Patient #5 was observed to be on isolation precautions and documented signage required staff to wear gown and glove. Employee G, RN was observed wearing a yellow gown and latex gloves while working in the room. Employee G prepared to administer insulin, which was sitting on her portable workstation that was staged just inside the patient's room. She handled the insulin vial and insulin syringe while wearing her latex gloves. She manipulated Patient #5 to identify administration site, which included coming in direct contact with the patient; injected the insulin and then disposed of the needle/syringe routinely in Sharps container. Employee G then turned to the portable workstation wearing the same gloves which contacted Patient #5. She returned the scanning gun to its storage; opened the insulin drawer on her cart and returned the Humalog insulin to this drawer which contained the following other vials of insulin: 2 vials of Novolog Mix 70/30; 1 vial of Levemir; and 1 vial of Humalin N. Employee G, RN then removed the gloves and washed hands routinely.


An interview was conducted on 4/24/2018 at 3:12 p.m. with Employee H, RN, and she confirmed that the facility did not prevent the insulin vials from going into the patients' rooms/direct patient care area and that Employee G should have been adhering to all isolation precautions, including taking off the gloves and gown prior to handling the medication.


An interview was conducted with the Chief Nursing Officer on 4/24/2018 at 3:32 p.m. She confirmed that there was nothing in policy form that prohibited taking multi-dose vials into multiple patient rooms.


An interview was conducted with Employee G on 4/25/2018 at 9:23 a.m. about her insulin administration to Patient #5, and she confirmed that she did take the scanner and the medication vial Humalog and put them back into their respective storage areas; she did not wipe down the workstation that was brought from room to room. She stated, "Oh my, that is right, she is on isolation and I was supposed to take my gloves off and cleanse hands before putting the scanner gun and the insulin bottle back away." She acknowledged the break in infection prevention requirements.


An interview was conducted with the Pharmacy Consultant for the facility on 4/25/2018 at 10:01 a.m., and she stated that she was contracted pharmacy service to the facility; "We are consulted on pharmacy policy and collaborate with the facility on interdisciplinary policy and procedures." She also confirmed that her facility implemented that all multi-dose medications (Insulin) must be pulled up in the medication room and not brought into direct patient care areas. She confirmed that in the past, the facility was recommended to adopt a multi-dose policy and procedure that limited exposure to patient care areas; however, the facility did not choose to adopt the policy and procedure at that time.


A review of the medical record for Patient #5 documented that the patient was on "Contact" precautions. Source documentation revealed for Respiratory H. Influenzae. Ordered on 4/12/2018.


The hospital's Infection Control Policy Subject Isolation Plan (Policy #INF 041), updated on 10/2018, documented the following procedures:

1. Don PPE when entering the patient's room on contact precaution and perform handwashing practice when leaving the room. Wash hands immediately with an Antimicrobial soap and water for C-Diff before leaving patient room/area.


2. Gloves and gowns shall be removed before leaving the patient's room and placed in the trash.


The CDC recommends contact precautions based on national or local regulations. Deems C-Diff to be of special clinical and epidemiological significance. Wear gloves whenever touching the patient's intact skin or surfaces and articles in close proximity to the patient (e.g., medical equipment, bed rails). Don gloves upon entry into the room. Don gown upon entry into the room. Remove gown and observe hand hygiene before leaving the patient-care environment. After gown removal, ensure that clothing and skin do not contact potentially contaminated environmental surfaces that could result in possible transfer of microorganisms to other patients or environmental surfaces.