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Based on record review, observation and interview, the hospital failed to ensure the infection control officer developed an effective system to identify and control infections of patients as evidenced by:

1) failing to institute contact precautions for a patient (Patient #R1) who had an order for contact precautions which was based on a history of a multi-drug resistant organism;

2) failing to provide documentation of action plans or teaching performed to improve hand hygiene;

3) failing to evaluate potential infection control breaches during Foley catheter insertion as a possible cause of catheter associated, hospital acquired urinary tract infections. 2 (#3, #5) of 5 (#1-#5) patients reviewed had hospital acquired catheter associated urinary tract infections.

4) failing to ensure a sanitary environment was maintained on the Medical/Surgical and Orthopedic Units on the 6th floor;

5) failing to maintain a sanitary environment in the Emergency Department (ED);

6) failing to remove PPE (personal protective equipment) before exiting surgical areas and entering the patient and staff cafeteria.


Findings:

1) Failing to institute contact precautions for a patient (Patient #R1) who had an order for contact precautions which was based on a history of a multi-drug resistant organism;

Review of the hospital policy titled Contact and Special Precautions, Number IP 4.3, revealed in part:
It is the intent of the hospital to use contact precautions for patients known or suspected to have serious illnesses easily transmitted by direct patient care or by contact with items in the patient ' s environment. Patients with a known history of a MDRO (multi drug resistant organism) within the last 6 months will also be placed in contact isolation.

Review of the medical record for Patient #R1 revealed an order dated 3/31/15 at 8:45 a.m. for contact precautions based on a history of a multi-drug resistant positive culture result.

In an observation on 4/1/15 at 12:30 p.m., various staff members were seen entering and exiting Patient #R1 ' s room without wearing PPE. There was an isolation cart outside of the door to his room, but no signage indicating he was on any precautions.

In an interview on 4/1/15 at 12:35 p.m. with S11RN, she said she was the nurse taking care of Patient #R1. S11RN said Patient #R1 had not been placed on contact precautions and she had not been using contact precautions although she suspected he might have needed precautions. S11RN verified Patient #R1 had an order for contact precautions written the day before on 3/31/15.

2) Failing to provide documentation of action plans or teaching performed to improve hand hygiene.

Review of the Hand Hygiene observation logs provided by the hospital revealed the following percentages of staff that performed hand hygiene correctly: September 2014:79%, October 2014:53%, November 2014: 54% and December 2014: 56%.

In an interview on 4/2/15 at 8:37 a.m. with S4InfectionControl, she indicated a lack of correct hand hygiene had been identified as an infection control issue in the hospital. S4InfectionControl said she did not have documentation of action plans or teaching done for the lack of hand hygiene identified in the hospital.

3) failing to evaluate potential infection control breaches during Foley catheter insertion as a possible cause of catheter associated, hospital acquired urinary tract infections. 2 (#3, #5) of 5 (#1-#5) patients reviewed had hospital acquired catheter associated urinary tract infections.

Patient #3
Review of Patient #3's medical record revealed an admission date of 10/20/14. Additional review revealed the patient had an indwelling Foley urinary catheter inserted in the hospital's ED on 10/20/14. Further review revealed the patient's catheter was removed and re-inserted on the following days: 10/22/14, 12/28/14, and 1/22/15.

Review of Patient #3's lab reports revealed a positive urine culture on 1/18/15. The isolated bacteria noted on the culture report was VRE (Vancomycin Resistant Enterococcus). This infection was classified as a catheter associated hospital acquired infection.

Patient #5
Review of Patient #5's medical record revealed an admission date of 3/1/15. Further review revealed the patient had an indwelling Foley urinary catheter inserted in the hospital's ED on 3/1/15.

Review of Patient #5's lab reports revealed a positive urine culture on 3/27/15. The isolated bacteria noted on the culture report was E. (Escherichia) Coli (MDRO). This infection was classified as a catheter associated hospital acquired infection.

In an interview on 4/1/15 at 3:59 p.m. with S1Quality, she indicated the majority of the urinary catheters inserted in the hospital were inserted in the ED. S1Quality also indicated observations of staff technique during Foley catheter insertion for identification of potential infection control breaches was not part of the hospital's infection control surveillance. She agreed breaches in infection control techniques during catheter insertion were potential sources of hospital acquired, catheter associated infections. S1Quality also agreed observations of catheter insertion should have been included in infection control surveillance.

In an interview on 4/2/15 at 9:20 a.m. with S4InfectionControl, she indicated part of the data collection for surveillance of potential causes of hospital acquired catheter associated infections was based upon identification of the unit where the catheter was inserted. She also indicated her observations included dependent loop positioning of the urine collection system and ensuring the catheters were secured properly. S4Infection control confirmed observations of staff technique during Foley catheter insertion for identification of potential infection control breaches was not part of the hospital's infection control surveillance. She agreed breaches in infection control techniques during catheter insertion were potential sources of hospital acquired, catheter associated infections.


4) Failing to ensure a sanitary environment was maintained on the Medical/Surgical and Orthopedic Units on the 6th floor.

Observations on the 6th floor on 3/31/15 from 1:25 p.m. until 2:30 p.m. revealed the following:
An observation was made at 1:25 p.m. of a room with a cart containing patients' bathroom supplies including toilet paper and soap. Further observation revealed there was a used paper cup on top of the cart, a discarded pair of gloves on a shelf and a discarded, wadded paper towel on top of the toilet paper. Various items of debris were located on the floor around the cart.

An observation at 1:40 p.m. revealed a sharps container in the medication room that was overflowing with a syringe protruding from the opening.

Observations of the units, within the time frame referenced above, revealed the clean linen carts located in the hall and in 2 supply rooms were uncovered.

An observation was made at 1:50 p.m.of a ceiling leak in a supply room off of the nurses station on the Ortho (Orthopedic ) Unit of the 6th floor. Two wet ceiling tiles (saturated) had fallen from the ceiling onto the floor. The ductwork was exposed and water was noted to be dripping into a basin on the floor. The leak was located above the area where sterile IV (intravenous) supplies (IV catheters and sterile dressings) were stored.

In an interview on 3/31/15 at 1:50 p.m. with S24RN, she said the staff had been aware of the ceiling leak and the saturated ceiling tiles that had fallen on the floor. She indicated it had been discovered earlier that morning when the day shift had started.

Review of the work order for the 6th floor (Ortho) ceiling leak repair revealed the request had been submitted at 14:18 (2:18 p.m.) on 3/31/15.

In an interview on 3/31/15 at 2:05 p.m. with S25PlantOps (Plant Operations Manager), he confirmed he had just received a work order for repair of the ceiling leak after the survey team had questioned staff about the leak.

An observation of Room B-605 revealed 3 broken patient beds in the room. One of the beds had an open Styrofoam food box (with food crumbs in it) laying on top of it. The garbage can in the room was overflowing onto the floor and a towel was noted on the floor in the bathroom. Debris was noted on the floor throughout the room. Several pairs of discarded gloves were observed on the beds, the floor and on a cabinet.

In an interview on 3/31/15 at 2:30 p.m. with S8EnvironmentalServices, he verified the above mentioned areas on the 6th floor should have been cleaned.

5) Failing to maintain a sanitary environment in the Emergency Department (ED).

In an observation on 3/31/15 at 2:55 p.m. in the ED, there were two dirty box fans stored in a clean supply room and a dirty suture cart stored in another clean supply room.

In an observation on 3/31/15 at 3:10 p.m., S10X-ray donned gloves, placed an X-ray plate under a patient, removed the plate, removed her gloves, then left the room without washing or sanitizing her hands.

In an interview on 3/3/15 at 3:15 p.m. with S9RNCharge, she verified the above mentioned findings. S9RNCharge said the dirty equipment should not have been stored in the clean areas and the X-ray technician should have performed hand hygeine after removing her gloves.

6) Failing to remove PPE (personal protective equipment) before exiting surgical areas and entering the patient and staff cafeteria.

Review of the hospital guidelines for surgical attire (per Association of periOperative Registered Nurses) revealed in part:

9. When going outside of the department, all PPE (hats, shoe covers, gloves, masks, etc.)must be removed.

In an observation on 4/1/15 between 11:30 a.m. and 11:40 a.m. in the cafeteria, 7 different staff members were observed entering the cafeteria and eating while still wearing their scrub hats. 2 of the staff members were wearing shoe covers.

In an interview on 4/1/15 at 11:40 a.m. with S2PatientCareServices, she said the staff members should not have worn their scrub hats and shoe covers outside of the Operating Room suites.













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