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NORTHEASTERN VERMONT REGIONAL HOSPITAL 1315 HOSPITAL DRIVE SAINT JOHNSBURY, VT 05819 May 2, 2017
VIOLATION: PATIENT CARE POLICIES Tag No: C0271
Based on observations, staff interviews and record review, the CAH failed to assure care and services were consistently provided in accordance with established policies and procedures for 1 applicable patient and for the proper disposal of contaminated blood-draw items. (Patient #2). Findings include:

1. Per observation on 5/1/17 at 11:40 AM Nurse #1 failed to follow CAH policies and procedures when drawing blood cultures ordered by Emergency Department (ED) provider for Patient #2. After bringing a cart containing Intravenous (IV) and blood-drawing supplies for laboratory blood tests into Room #9, Nurse #1 was observed preparing 2 blood culture bottles by removing the sealed caps off the top of each bottle and swabbing the top rubber septum with ChloraPrep swabstick (Chlorhexidine gluconate 2% and isopropyl alcohol 70 % ) an antiseptic/antimicrobial used in cleansing skin before needle insertion. Nurse #1 donned gloves, applied a blood pressure cuff instead of using a tourniquet to increase venous pressure and to identify a prominent vein to access. The nurse cleansed Patient #2's left arm near the antecubital area again using ChloraPrep, swabbing for approximately 10 seconds, followed by palpating the prospective needle insertion site. The needle insertion performed by Nurse #1 failed to access the vein subsequently the nurse removed the needle and determined Patient #2 required further intervention in order to achieve venous access to obtain blood cultures and starting an IV. Nurse #1 was observed discarding some of the contaminated equipment into a biohazard container located on top of the cart. Nurse #1 then removed the cart from Room #9 and transported it to the opposite side of the ED where s/he used CaviWipes towelettes to disinfect the cart.

Per review of the CAH's Blood Culture Collection policy last revised on 8/1/16 states: 5. "apply the tourniquet"; 6. "select the venipuncture site and vein" and once venipuncture site is selected 7. "release the tourniquet". Nurse #1 failed to use the tourniquet and did not release/deflate the Blood Pressure cuff. The policy further states: 9. "Remove the blood culture bottle caps and cleanse using alcohol prep ". Nurse # 1 cleansed the blood culture bottles with the Chlorhexidine Gluconate swabstick. When cleansing the venipuncture site the policy states to use Chlorhexidine Gluconate swabstick and to "iii. Use gentle back and forth strokes for a minimum of 30 seconds." During the observation, Nurse #1 swabbed the venipuncture site for approximately 10 seconds. In addition, after cleansing the site, Nurse #1 contaminated the cleansed area by re-palpation of the perspective venous access site with gloved fingers prior to attempted insertion.

Per interview on 5/1/17 at 2:40 PM, Nurse #1 confirmed s/he had probably contaminated the venous access site after cleansing and failed to appropriately prep the skin sufficiently. Per interview on 5/2/17 at 9:45 AM, the ED Nurse Manager confirmed Nurse #1 had failed to follow CAH policy during the procedure for obtaining blood cultures and IV access. It was also confirmed, the use of a blood pressure cuff instead of a tourniquet was inappropriate and not in accordance with policy.

2. Per observation on 5/1/17 at 11:18 AM a lab technician was observed exiting the ED into a public hallway wearing gloved hands holding blood culture bottles. When asked where s/he was going with the bottles the technician stated s/he was unable to successfully obtain physician ordered blood cultures on a patient in the ED and was going to dispose of the used bottles in the CAH laboratory, stating unable to locate the biohazard container within the ED to dispose of the blood culture bottles. Per interview at 1:20 PM on 5/1/17, the Laboratory Manager confirmed technicians must dispose all venipuncture/blood collection equipment immediately after use within the location where the blood-drawing phlebotomy procedure was performed and/or attempted to prevent risk of cross contamination. It was further confirmed by the ED Nurse Manager on 5/2/17 at 9:50 AM, the ED indeed had a special biohazard container specifically sized to place contaminated blood culture bottles. In addition, per Blood Culture Collection policy staff are to "22. Dispose of contaminated materials....." and "23. Remove gloves and sanitize hands". The expectation this process is all performed within the location where laboratory staff have conducted the venipuncture, not traveling in hallways with contaminated gloves and used culture bottles.
VIOLATION: POLICIES - INFECTION CONTROL Tag No: C0278
Based on observation, interview and record review, the Infection Control Program failed to ensure that staff consistently maintained infection control standards of practice throughout all areas and departments of the hospital. Findings include:

Per record review, Patient #2 has a health history which includes a contagious liver disease spread through contact with the blood of an infected individual. On 5/1/17 the ED physician ordered blood cultures to be obtained from Patient #2 due to a potential diagnosis of cellulitis. Per observation on 5/1/17 at 11:40 AM Nurse #1 failed to maintain appropriate infection control practices when performing a venipuncture site access for the purpose of obtaining blood cultures. The nurse cleansed Patient #2's left arm near the antecubital area using ChloraPrep swabstick, swabbing insufficiently and inadequately, cleaning the skin site for approximately 10 seconds instead of at least 30 seconds or more to assure reduction of skin pathogens which could contaminate the blood sample. Nurse #1 then re-palpated the prospective needle insertion site, again creating a second opportunity for contamination of the blood sample. The needle insertion performed by Nurse #1 failed to access the vein and subsequently the nurse removed the needle and determined Patient #2 required further intervention in order to achieve venous access to obtain blood cultures and starting an IV. Nurse #1 was observed discarding some of the contaminated equipment into a biohazard container located on top of the cart. Nurse #1 then removed the cart from Room #9 and transported it to the opposite side of the ED where s/he used CaviWipes (disinfectant) towelettes to sanitize the cart.

Per interview on the 5/1/17 at 3:35 PM, the Infection Preventionist confirmed Nurse #1 had not maintained effective infection control practices to include failing to clean the IV cart prior to removing from Patient #2's ED room. Due to the fact Patient #2 has a diagnosis of an infectious disease, and the possibility of cross-contamination of the cart surface with equipment used during Nurse #1's attempt to achieve venipuncture access, the expectation would be that the nurse, would dispose of all used equipment in the biohazard container and wipe cart with CaviWipes while still in the patient's assigned ED room. Instead Nurse #1 removed the cart from the room and positioned it in the hallway near the far end of the nurse's station and proceeded to clean the cart surfaces.

Per interview on 5/2/17 at 9:45 AM, the ED Nurse Manager confirmed Emergency Services has had higher incidents of blood culture contamination. The Manager further acknowledge the effect this has on patients and the consequences when false culture readings result in patients being treated with unnecessary antibiotics. Although there has been some previous training provided to ED nursing staff, the Manager further acknowledge more training was necessary to assure staff follow infection control practices and CAH policies and procedures. The Manager also confirmed, Nurse #1 should have completed the cleansing and disinfecting of the IV cart surfaces prior to removal from the room occupied by Patient #2.

Per Journal of Clinical Microbiology, March 1997, p. 563-565 vol 35, No. 3 Doing it Right the First Time: Quality Improvement and Contaminant Blood Culture states contaminated blood cultures "..are associated with with increased length of stay, inappropriate administration of antibiotics, use of further testing, resulting in more than 50 % greater total hospital charges."

2. Per observation on 5/1/17 at 11:18 AM a lab technician was observed exiting the ED into a public hallway wearing gloved hands holding blood culture bottles. When asked where s/he was going with the bottles the technician stated s/he was unable to successfully obtain physician ordered blood cultures from an ED patient and was going to dispose of the used bottles in the CAH laboratory, stating s/he was unable to locate the biohazard container within the ED to dispose of the blood culture bottles. Per interview at 1:20 PM on 5/1/17, the Laboratory Manager confirmed technicians must dispose all venipuncture/blood collection equipment immediately after use within the location where the blood-drawing phlebotomy procedure was performed and/or attempted, to prevent risk of cross contamination. It was further confirmed by the ED Nurse Manager on 5/2/17 at 9:50 AM, the ED indeed had a special biohazard container specifically sized to place contaminated blood culture bottles. The Infection Preventionist also acknowledged on 5/1/17 at 3:35 PM, there was a biohazard receptacle in the ED for disposal of blood culture bottles and laboratory staff should have used this container instead of walking in a public hallways with contaminated items.