The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

MONUMENT HEALTH RAPID CITY HOSPITAL 353 FAIRMONT BLVD POST OFFICE BOX 6000 RAPID CITY, SD 57701 March 11, 2015
VIOLATION: NURSING SERVICES Tag No: A0385
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
















Based on observation, interview, record review, and policy review, the provider failed to ensure the nursing staff:
*Followed isolation precautions according to the provider's policy and procedures for timely implementation of infection control procedures for four of four sampled patients (5, 8, 9, and 16) with communicable diseases.
*Enforced isolation policy and procedures related to personal protective equipment (PPE) for visitors of three of eight observed patients on isolation precautions.
*Performed hand hygiene during one of one observed PICC ([peripherally inserted central catheter] the catheter is placed in the vein that carries unoxygenated blood from the upper half of the body to the upper right side of the heart) line flushing for patient 11 by one of one registered nurse (RN) B.
*Appropriately disinfected one of one blood glucose meter after the meter was used for one of one patient (19) who had methycillin resistant staphylococcus auerus and influenza A by one of one patient care technician (PCT) N.
*Posted the appropriate isolation signage in two of two imaging departments (computed tomography [CT] and special procedure department).
*Implemented interventions on 18 of 18 sampled patient's (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, and 18) care plans related to the appropriate isolation precautions.
*Provided documentation of patients and visitors isolation precaution education for 16 of 18 sampled patients (1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 14, 15, 16, 17, and 18).
Findings include:

1. Review and interview on 3/10/15 at 4:20 p.m. with registered nurse (RN) O of patient 9's medical record revealed:
*He had been admitted on [DATE] and expired on [DATE].
*His admitting diagnoses included [DIAGNOSES REDACTED]
*The diagnosis of [DIAGNOSES REDACTED].
*He had a history of TB back in 1958.
*He had not been eating and had lost twenty pounds in the past month.
*He had stopped taking his rheumatoid arthritis medication methotrexate several days ago.
*Methotrexate lowers a person's immune system and making the person more susceptible to getting infections.
*A pulmonary note dated 2/21/15 indicated cytology (study of cells) for a series of tests that included Acid Fast Bacilli (AFB test for [DIAGNOSES REDACTED]).
*On 2/23/15 a laboratory (lab) report indicated he was positive for TB.
*The patient had been admitted through the emergency room , transferred from the Rapid Admission Unit to the surgical intensive care unit (ICU), and then transferred to intensive ICU after his diagnosis of [DIAGNOSES REDACTED]
*It was troubling the patient had so many visitors and not all visitors would comply all the time with the isolation protocol.
*There were many potential staff exposures to TB, because airborne isolation protocols were not immediately initiated.

Interview on 3/11/15 at 8:00 a.m. with the occupational health nurse revealed:
*She had received numerous staff names of potential TB exposures from staff caring for patient 9.
*She would start staff post-exposure TB skin testing in ten to twelve weeks to identify any staff members that may be convertors. Any staff exhibiting signs and symptoms or testing positive would be treated in accordance with the Centers for Disease and Prevention guidelines.

Interview on 3/11/15 at 8:20 a.m. with infection control coordinator (ICC) F regarding patient 9 revealed:
*The patient had a history of TB in 1958.
*He had been on methotrexate which could cause depression of the immune system making him more susceptible to infections.
*His physician at the time of admission was not considering TB but Systemic Inflammatory Response Syndrome (SIRS). His physician had informed her he did not think the patient would be positive for TB and isolation precautions were not necessary.
*With him being in a weakened condition and poor health it was possible to develop TB.
*The nursing staff should have initiated airborne isolation precautions for TB when the physician first sent a specimen testing for TB.
*Airborne precautions would have been appropriate until active TB was not a concern to protect staff and visitors.
*The nursing staff per policy were able to initiate isolation protocols whenever there was a diagnosis or suspicion of a communicable disease. A physician's order for the isolation would have been obtained as a verbal or telephone order.
*The nursing staff should have initiated airborne isolation precautions promptly. That would have prevented potential exposure to other patients, staff, and visitors.
*She was aware the patient's medical records did not reflect when the patient had been placed in isolation.
*He had many visitors, and it was difficult to get all of them to be compliant with wearing a mask, gown, and gloves when entering the room and keeping the PPE on during their visit.
*The hospital policy was to encourage no more than two visitors at a time in the isolation rooms.
*Numerous family members had been repeatedly educated on the importance of wearing PPE.
*She was aware the nursing staff did not consistently initiate isolation protocols when patient's had a communicable disease. That became clear if the patient was admitted on a Friday. When she returned to work on Monday, and reviewed her list of patients with communicable diseases the patient's chart did not always indicate when the isolation had been initiated.
*She had identified isolation protocol breaches to include not starting isolation when required and staff members not performing hand hygiene when required.
*She had in the past informed floor managers of staff breaches in infection control and nothing was done. There was no "Support from administrative staff" regarding infection control implementation.

Review of the provider's October 2014 Strict Airborne Precautions (IC-8415-030) policy revealed:
*"Strict Airborne Isolation is designed to prevent transmission of highly contagious or virulent infections that may be spread by both air and contact.
*The patients were placed in a private room that had monitored negative air pressure.
*PPE included gloves, gown, and a mask. The gloves should have been put on prior to entering the room, a gown should have been worn if touching the patient, and a mask should have been worn if you had a compromised immune system.
*Encourage only two visitors at a time.

Review of the provider's August 2014 [DIAGNOSES REDACTED] Control Program policy revealed:
*"Any patient with confirmed or suspected active TB is to be placed in TB isolation until infectiousness is ruled out or adequate therapy and complete cure is confirmed.
*Any incident of noncompliance with isolation protocol must be reported to your supervisor, Infection Control, or Occupational Health.
*For appropriate interventions, infection control and the patient's physician must be notified if the patient will not comply with isolation protocols.
*The physician and/or nurse are to provide education to the patient in isolation and their visitors."

2. Review and interview on 3/10/15 at 4:20 p.m. with RN O of the medical record for patient 8 revealed:
*The patient had been admitted through the Rapid Admission Unit on 2/13/15.
*On 2/13/15 at 7:39 p.m. lab had informed the nursing staff the patient was positive for clostridium difficile ([DIAGNOSES REDACTED] is a highly contagious infection in the intestines [bowels] that causes diarrhea).
*On 2/16/15 documentation from the infection control staff stated "Should be placed on [DIAGNOSES REDACTED] precautions."
*The documentation in the medical record indicated isolation precautions were initiated on 2/16/15.

3. Review and interview on 3/11/15 at 4:30 p.m. with RN F of the medical record for patient 16 revealed:
*He had been admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]
*On 2/22/15 at 8:00 p.m. the lab had informed the nursing staff the patient was positive for Influenza B.
*There was no documentation in the patient's medical record he had been placed on isolation precautions until 2/23/15.
*The patient should have been placed on droplet isolation precautions when the nursing staff were notified by lab of the positive Influenza B test result.
*Droplet precautions prevented infectious diseases that were transmitted through the air.
*A surgical mask should have been worn when working within six feet of the patient.

4. Review of patient 5's medical record revealed:
*She had been admitted on [DATE].
*She was discharged on [DATE].
*Her diagnoses and symptoms included:
-Seizures.
-Renal (kidney) disease.
-Diarrhea.
*She had a history (July 2014) of [DIAGNOSES REDACTED].
*On 2/14/15 she had a positive confirmation of [DIAGNOSES REDACTED] in her feces (stool).
*There was no documentation found in her medical record that isolation precautions had been implemented on her admission to the hospital due to her symptoms of [DIAGNOSES REDACTED]
*There was no documentation until 2/16/15 that was two days after her positive lab results on 2/14/15 and was three days after her initial admission to the hospital.

Review of patient 5's 2/14/15 Specimen Inquiry sheet revealed:
*She was positive for [DIAGNOSES REDACTED].
*There was documentation the lab personnel had called a nurse on the floor where the patient was residing on 2/14/15 at 1559 (3:59 p.m.).

Review of patient 5's nursing assessments from 2/13/15 through 2/16/15 revealed:
*There had been no documentation of the positive [DIAGNOSES REDACTED] confirmation from the lab.
*There was no documentation until 2/16/15 regarding the positive [DIAGNOSES REDACTED] findings, and that documentation was from the infection control staff.

Review of patient 5's nurses notes documentation on 2/16/15 at 10:20 a.m. revealed "Reviewing chart per Nursing Assessment request. Patient should be placed on Contact Precautions (CD) for Clostridium Difficile. Please inform the doctor that the patient has been placed on these precautions. Continue to follow Standard Precautions and wash hands with running water and soap."

Review of patient 5's 2/14/15 plan of care revealed there was no documentation for the following:
-Her positive history of [DIAGNOSES REDACTED] in July 2014.
-Her current positive lab specimen for [DIAGNOSES REDACTED] on 2/14/15.
-Any interventions that would have been put in place including contact precautions.

Interview on 3/9/15 at 3:15 p.m. with RN U during patient 5's chart review revealed:
*She was on contact precautions that meant anyone entering the room should have worn a gown and gloves.
*She was unsure if any teaching had been completed for the patient or her family regarding the [DIAGNOSES REDACTED].
*The room was monitored by the staff at the nurses station.
*The patient was confused at times.
*She was admitted with seizures and diarrhea.
*The patient had a history of [DIAGNOSES REDACTED] in July 2014.
*She was confirmed with positive [DIAGNOSES REDACTED] on 2/14/15.

5. Observation on 03/09/15 at 3:03 p.m. revealed two visitors in rooms 1005 and 1027 had not put on PPE. The isolation patient in room 1005 was on Multidrug Resistant (MDR) precautions. Instructions posted outside the room indicated staff and visitors were to wear gloves, a mask, and a gown. The isolation patient in room 1027 was on droplet precautions. The sign outside the room indicated employees and visitors were to wear a mask while in the room.

Interview with employee P at the time of the above observation revealed visitors had been instructed to wear the PPE, but if they refused there was nothing the facility staff could have done. Interview on 03/09/15 at 3:04 p.m. with the employee Q confirmed employee P's statement.

6. Observation on 3/9/15 at 3:45 p.m. of room 309 revealed:
*Droplet and contact isolation precautions signage was posted outside the door.
*A male visitor was holding patient 3 inside the room.
*The male visitor was not wearing any PPE.

Interview at the time of the above observation with the director of professional practice revealed the visitor should have worn PPE.

Interview on 3/11/15 at 9:25 a.m. with the women and children services director revealed:
*Patients' family members were supposed to gown and glove.
*The provider struggled getting family members to wear PPE.
*She was not aware of any provider policy that required family members to wear PPE.

Review of the provider's September 2014 General Information for Isolation Precautions policy revealed all visitors to an isolation room should have followed the guidelines for that type of isolation.

7. Observation and interview on 3/10/15 at 9:00 a.m. with RN J during a PICC line flush with patient 11 revealed she:
*Had been employed nine months with the provider.
*Placed the appropriate mask over her nose and mouth.
*Washed her hands prior to entering the patients room.
*Flushed the patient's PICC line with normal saline without wearing gloves.
*Left the room and washed her hands after the procedure.

Interview with director of the medical floor X immediately following the above observation revealed she did not believe staff needed to wear gloves during the flushing of a patient's PICC line.

Review of the provider's October 2014 Central Venous Access Devices policy revealed the nurse should wash hands and place nonsterile gloves on hands prior to flushing the PICC line.

8. Observation on 3/10/15 at 8:25 a.m. with PCT N after the blood glucose had been obtained from patient 11 revealed:
*She wiped the blood glucose meter with the disinfectant Steriplex.
*She then immediately placed the blood glucose meter in the docking station setting on top of the nurses station.

Interview on 3/10/15 at 8:35 a.m. with RN O and the director of professional services regarding the above observation with PCT N revealed:
*The Steriplex needed to stay wet on the surface of the blood glucose meter for five minutes.
*They both agreed that had not been done by PCT N.

Review of the provider's January 2015 Nova StatStrip Glucose Meter policy revealed:
*Each meter should have been disinfected prior to use for another patient.
*Each meter should have been wiped down with a germicidal wipe as approved by the lab on all exterior surfaces.
*Squeeze the germicidal wipes to remove excess liquid and carefully wipe the meter.
*Immediately follow with a water-dampened cloth or paper towel to remove all cleaning residue.
*Dry thoroughly with a soft cloth or lint-free tissue.

Interview on 3/11/15 at 10:00 a.m. with infection control director S regarding the disinfection of the blood glucose meter revealed:
*Contact time with the Steriplex was five minutes.
*The glucose meter should not have been placed back into the docking station immediately after cleaning the machine with Steriplex.
*She agreed the policy and procedure did not reflect the procedure that was done by PCT N.
*The teaching for all staff included Steriplex would have been used to disinfect the glucose meter. Steriplex needed a five minute contact time for a complete kill of Clostridium difficile spores, bacteria, viruses, and fungi.

9. Observation on 3/10/15 at 9:10 a.m. revealed patient 10 was transported from his isolation room down to the Specials Procedure Department for a PICC line placement. During transport the patient and staff had appropriate PPE on. The patient had been on methicillin-resistant staphylococcus aureus (MRSA is a contagious infection) precautions on the nursing unit. At the end of the case the patient was transported to the CT scanner with appropriate PPE.

Observation at the conclusion of patient 10's above procedure revealed physician B removed his contaminated gown and gloves, did not perform hand hygiene, documented on a form in the patient's chart, and exited Specials Room 11. Physician B was observed talking with staff in the adjacent procedure room, and he eventually exited the control room without performing hand hygiene.

Observation at the end of the above case revealed environmental services (ES) staff member W was waiting in the hallway outside procedure room 11. Interview at that time with ES W revealed:
*She had been sent by her supervisor to clean that procedure room.
*She was unsure if the patient that had just left had been on isolation.
*She stated her supervisor had not informed her if the patient had been on isolation.
*She was unsure of the name of the chemicals she would have used to disinfect the procedure room.
*She did not know about the chemical or how long (contact time) equipment surfaces needed to stay wet in order for the disinfectant to have been effective.
*There were no signs posted outside the room to inform staff about the type of isolation or what PPE should have been worn prior to entering the room.

After the patient's PICC procedure he was taken to the CT room. Observation in the CT Department and the room patient 10 was being scanned in revealed there were no isolation signs posted informing staff of the appropriate isolation protocols or the type of isolation the patient was on.

Interview on 3/11/15 at 11:37 a.m. with the environmental director revealed:
*The only reason ES staff were sent to the radiology departments was to clean a room after an isolation patient had been treated.
*The staff in the Specials Department and in the CT department should have posted isolation signs according to the infection the patient had.
*The isolation signs would have informed environmental services what type of isolation and what type of PPE should have been worn by the staff.

10. Review of patient 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 14, 15, 16, 17, and 18's medical records revealed no documentation of specific isolation education for the patient and their visitors.

11. Review of patient 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, and 18's medical records revealed none of the patients had documentation of isolation precautions or interventions in their care plans.

12. Review of the provider's October 2014 Placing a Patient in Isolation policy revealed:
*The healthcare provider would explain the purpose of isolation to the patient and their support person.
*An isolation handout would be made available to the above.
*No mention of documentation of isolation precautions or interventions in the patient's care plan.

Review of the provider's September 2014 general information for isolation precautions revealed:
*Staff should document initiation and discontinuation of isolation.
*Staff should chart maintenance of isolation at least once every shift.
-Computer entry should have been under care activity in the electronic medical record.
*Visitors would have been provided an information sheet that would have addressed questions and provided expectations while they visited a patient in isolation precautions.

Interview on 3/11/15 at 9:15 a.m. with the director of risk and safety revealed:
*Education specific to isolation was not documented in the patient's medical record.
*The patient's care plan had no documentation of isolation precautions and interventions.
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on record review, policy review, and interview, the provider failed to ensure:
*Documentation of patients and visitors isolation precautions education for 16 of 18 sampled patients (1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 14, 15, 16 ,17, and 18).
*Care plans were updated to include isolation precautions and interventions for 18 of 18 sampled isolation patients (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, and 18)
Findings include:

1. Review of the above listed patients' medical records revealed only patients 9 and 13 had documentation of specific isolation education for the patient and their visitors.

2. Review of the above listed patients' medical records revealed none of the patients had documentation of isolation precautions or interventions in their care plans.

3. Review of the provider's October 2014 Placing a Patient in Isolation policy revealed:
*The healthcare provider would explain the purpose of isolation to the patient and their support person.
*An isolation handout would be made available to the above.
*No mention of documentation of isolation precautions or interventions in the patient's care plan.

Review of the provider's September 2014 general information for isolation precautions revealed:
*Staff should document initiation and discontinuation of isolation.
*Staff should chart maintenance of isolation at least once every shift.
-Computer entry should have been under care activity in the electronic medical record.
*Visitors would have been provided an information sheet that would have addressed questions and provided expectations while they visited a patient in isolation precautions.

Interview on 3/11/15 at 9:15 a.m. with the director of risk and safety revealed:
*Education specific to isolation was not documented in the patient's medical record.
*The patient's care plan had no documentation of isolation precautions and interventions.
VIOLATION: INFECTION CONTROL Tag No: A0747
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, and policy review, the provider failed to:
*Assess, identify, and implement isolation precautions for four of four sampled patient (5, 8, 9, and 16) with a communicable disease.
*Post the appropriate isolation signage in two of two imaging departments (computed tomography [CT] and special procedure department).
*Ensure patient visitors followed posted isolation instructions for appropriate personal protective equipment (PPE) usage for three of eight observed patients with a communicable disease.
*Ensure documentation of isolation education for patient and their visitors for 16 of 18 sampled patients (1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 14, 15, 16 ,17, and 18) with a communicable disease.

Those failures represented an Immediate Jeopardy (IJ). On 3/11/15 at 3:15 p.m., an IJ was declared regarding infection control. The hospital's leadership staff (Vice-President of Quality, Safety and Risk Management and Interim Vice-President of Patient Care Services) were notified of the IJ situation. An acceptable abatement (resolution) plan was received and approved by the survey team, and the IJ was abated on 3/11/15 at 8:00 p.m.

This deficiency remained at the condition-level after the abatement of the IJ and implementation of the abatement plan was verified by the survey team at 3/11/15 at 8:00 p.m.

The provider's immediate plan of correction was as follows:
*Documentation of Precautions:
-1."By 2100 [9:00 p.m.], all patients currently on infection control precautions and without an order for precautions will have precautions noted on a Meditech Nursing order. All patients will have a Nursing Note documenting type of precaution, education, and reason(s) education has not been completed if applicable. The Nursing Note will be signed by the primary RN [registered nurse]. Completion Date 3/11/15. Responsible Person Interim Vice-President of Patient Care Services.
-2. Any newly admitted or identified patient needing infection control precautions will have a Meditech Nursing or Provider order and Nursing Notes with type of precaution, education, and reason(s) education has not been completed if applicable. The Nursing Note will be validated by the primary RN and Clinical Resource Nurse or Hospital Coordinator or second staff member until all staff responsible for plans of care have been educated. Completion Date 3/11/2015. Responsible Person Interim Vice-President of Patient Care Services.
-3. When Infection Control identifies a need for precautions, they will document an accurate description of the current status of precautions, i.e., in place or needed. Completion Date 3/12/15. Responsible Person Interim Vice-President of Patient Care Services."
*Documentation of Plan of Care and Patient/Family Education:
-1. By 2100, all patients currently on infection control precautions will have a plan of care which includes type of precaution and patient/family education documented in the medical record. If patients and/or families cannot be educated due to patient condition or family availability this will be documented in the Nursing Notes. Completion Date 3/11/15. Responsible Person Interim Vice-President of Patient Care Services.
-2. Any patient admitted and needing infection control precautions will have a plan of care which includes type of precaution and patient/family education documented when precautions are ordered. If patients and/or families cannot be educated due to patient condition or family availability this will be documented in the Nursing Notes. Completion Date 3/11/15. Responsible Person Interim Vice-President of Patient Care Services.
*Leadership Support: Staff will be instructed to follow the chain of command if there is any patient and/or family noncompliance with precautions. Patient non-compliance with precautions Patient noncompliance, notification of leadership, and actions taken will be documented in the Nursing notes. Completion Date 3/11/15. Responsible Person the President.
*Infection Control Availability:
-1. The Director of Infection Control is on-call tonight and will provide an on-call schedule to Communications by 3/12/2015. Completion Date 3/11/15. Responsible Person Vice-President Quality, Safety, and Risk Management.
-2. Staff will be notified that Infection Control staff can be contacted through Communications 24/7 should there be any questions. Completion Date 3/11/5. Responsible Person Vice-President of Quality, Safety, and Risk Management.

*Documentation Education: All Registered Nurses responsible for patients' plans of care will be educated (permanent, PRN, and Temporary) regarding the documentation requirements prior to next shift worked Persons on Leave of Absence or personal leave will be educated prior to next shift worked. Completion date 3/31/15. Responsible Person Interim Vice-President of Patient Cares Services.

*Hand Hygiene: All staff involved in direct patient care will receive education regarding key points in hand hygiene. Persons on Leave of Absence or personal leave will be educated prior to next shift worked. Completion Date 3/31/15. Responsible Person President.

*Monitoring of Documentation Education: Department Directors or designee will provide up-to-date education checklists to the Interim Vice-President of Patient Care or designee each business day morning until all staff is education. Completion Date 3/11/15. Responsible Person Interim Vice-President of Patient Care Services.

*Monitoring of hand Hygiene Education and Accountability:
-1. Department Directors or designee will provide up-to-date education checklists to the Vice President of Quality, Safety, and Risk Management or designee each business day morning until all staff is educated. Completion Date 3/13/15. Responsible Person Vice President Quality, Safety, and Risk Management.
-2. The President will send an all-user letter to Caregivers and providers setting expectations and consequences for non-compliance with hand hygiene. Completion Date 3/13/15. Responsible Person President.
-3. A trained team of auditors will continue to audit compliance with hand hygiene on a weekly basis. Completion Date 3/12/15. Responsible Person Director of Infection Control.
-4. Caregiver or physicians not in compliance with hand hygiene will have progressive discipline initiated. Completion Date Ongoing. Responsible Person President."

The IJ abatement plan was signed by the Chief Executive Officer (President) and Vice-President of Patient Care Services on 3/11/15 at 7:55 p.m.

Findings include:

1. Interview on 3/10/15 at 8:20 a.m. with assistant director T on the medical floor in regards to positive TB patient 11 revealed:
*There was no way to stop family or visitors from entering a patient's isolation room.
*The pink isolation sign outside the patient's room should have alerted visitors.
*Everyone entering the patient's room should have had a mask on. The visitors should have been sanitizing or washing their hands with soap and water upon entering and leaving the room.

Interview on 3/10/15 at 3:00 p.m. with RN J regarding the care of a TB patient revealed she was unaware of the provider's TB policy regarding visitors wearing regular masks upon entering patient 11's room.

2. Review and interview on 3/10/15 at 4:20 p.m. with registered nurse (RN) O of patient 9's medical record revealed:
*He had been admitted on [DATE] and expired on [DATE].
*His admitting diagnoses included [DIAGNOSES REDACTED]
*The diagnosis of [DIAGNOSES REDACTED].
*He had a history of TB back in 1958.
*He had not been eating and had lost twenty pounds in the past month.
*He had stopped taking his rheumatoid arthritis medication methotrexate several days ago.
*Methotrexate lowers a person's immune system and making the person more susceptible to getting infections.
*A pulmonary note dated 2/21/15 indicated cytology (study of cells) for a series of tests that included Acid Fast Bacilli (AFB test for [DIAGNOSES REDACTED]).
*On 2/23/15 a laboratory (lab) report indicated he was positive for TB.
*The patient had been admitted through the emergency room , transferred from the Rapid Admission Unit to the surgical intensive care unit (ICU), and then transferred to intensive ICU after his diagnosis of [DIAGNOSES REDACTED]
*It was troubling the patient had so many visitors and not all visitors would comply all the time with the isolation protocol.
*There were many potential staff exposures to TB, because airborne isolation protocols were not immediately initiated.

Interview on 3/11/15 at 8:00 a.m. with the occupational health nurse revealed:
*She had received numerous staff names of potential TB exposures from staff caring for patient 9.
*She would start staff post-exposure TB skin testing in ten to twelve weeks to identify any staff members that may be convertors. Any staff exhibiting signs and symptoms or testing positive would be treated in accordance with the Centers for Disease and Prevention guidelines.

Interview on 3/11/15 at 8:20 a.m. with infection control coordinator (ICC) F regarding patient 9 revealed:
*The patient had a history of TB in 1958.
*He had been on methotrexate which could cause depression of the immune system making him more susceptible to infections.
*His physician at the time of admission was not considering TB but Systemic Inflammatory Response Syndrome (SIRS). His physician had informed her he did not think the patient would be positive for TB and isolation precautions were not necessary.
*With him being in a weakened condition and poor health it was possible to develop TB.
*The nursing staff should have initiated airborne isolation precautions for TB when the physician first sent a specimen testing for TB.
*Airborne precautions would have been appropriate until active TB was not a concern to protect staff and visitors.
*The nursing staff per policy were able to initiate isolation protocols whenever there was a diagnosis or suspicion of a communicable disease. A physician's order for the isolation would have been obtained as a verbal or telephone order.
*The nursing staff should have initiated airborne isolation precautions promptly. That would have prevented potential exposure to other patients, staff, and visitors.
*She was aware the patient's medical records did not reflect when the patient had been placed in isolation.
*He had many visitors, and it was difficult to get all of them to be compliant with wearing a mask, gown, and gloves when entering the room and keeping the PPE on during their visit.
*The hospital policy was to encourage no more than two visitors at a time in the isolation rooms.
*Numerous family members had been repeatedly educated on the importance of wearing PPE.
*She was aware the nursing staff did not consistently initiate isolation protocols when patient's had a communicable disease. That became clear if the patient was admitted on a Friday. When she returned to work on Monday, and reviewed her list of patients with communicable diseases the patient's chart did not always indicate when the isolation had been initiated.
*She had identified isolation protocol breaches to include not starting isolation when required and staff members not performing hand hygiene when required.
*She had in the past informed floor managers of staff breaches in infection control and nothing was done. There was no "Support from administrative staff" regarding infection control implementation.

Review of the provider's October 2014 Strict Airborne Precautions (IC-8415-030) policy revealed:
*"Strict Airborne Isolation is designed to prevent transmission of highly contagious or virulent infections that may be spread by both air and contact.
*The patients were placed in a private room that had monitored negative air pressure.
*PPE included gloves, gown, and a mask. The gloves should have been put on prior to entering the room, a gown should have been worn if touching the patient, and a mask should have been worn if you had a compromised immune system.
*Encourage only two visitors at a time.

Review of the provider's August 2014 [DIAGNOSES REDACTED] Control Program policy revealed:
*"Any patient with confirmed or suspected active TB is to be placed in TB isolation until infectiousness is ruled out or adequate therapy and complete cure is confirmed.
*Any incident of noncompliance with isolation protocol must be reported to your supervisor, Infection Control, or Occupational Health.
*For appropriate interventions, infection control and the patient's physician must be notified if the patient will not comply with isolation protocols.
*The physician and/or nurse are to provide education to the patient in isolation and their visitors."

3. Review and interview on 3/10/15 at 4:20 p.m. with RN O of the medical record for patient 8 revealed:
*The patient had been admitted through the Rapid Admission Unit on 2/13/15.
*On 2/13/15 at 7:39 p.m. lab had informed the nursing staff the patient was positive for clostridium difficile ([DIAGNOSES REDACTED] is a highly contagious infection in the intestines [bowels] that causes diarrhea).
*On 2/16/15 documentation from the infection control staff stated "Should be placed on [DIAGNOSES REDACTED] precautions."
*The documentation in the medical record indicated isolation precautions were initiated on 2/16/15.

4. Review and interview on 3/11/15 at 4:30 p.m. with RN F of the medical record for patient 16 revealed:
*He had been admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]
*On 2/22/15 at 8:00 p.m. the lab had informed the nursing staff the patient was positive for Influenza B.
*There was no documentation in the patient's medical record he had been placed on isolation precautions until 2/23/15.
*The patient should have been placed on droplet isolation precautions when the nursing staff were notified by lab of the positive Influenza B test result.
*Droplet precautions prevented infectious diseases that were transmitted through the air.
*A surgical mask should have been worn when working within six feet of the patient.

5. Observation on 3/10/15 at 9:10 a.m. revealed patient 10 was transported from his isolation room down to the Specials Procedure Department for a peripherally inserted central catheter (PICC) line placement. During transport the patient and staff had appropriate PPE on. The patient had been on methicillin-resistant staphylococcus aureus (MRSA is a contagious infection) precautions on the nursing unit. At the end of the case the patient was transported to the CT scanner with appropriate PPE.

Observation at the conclusion of patient 10's above procedure revealed physician B removed his contaminated gown and gloves, did not perform hand hygiene, documented on a form in the patient's chart, and exited Specials Room 11. Physician B was observed talking with staff in the adjacent procedure room, and he eventually exited the control room without performing hand hygiene.

Observation at the end of the above case revealed environmental services (ES) staff member W was waiting in the hallway outside procedure room 11. Interview at that time with ES W revealed:
*She had been sent by her supervisor to clean that procedure room.
*She was unsure if the patient that had just left had been on isolation.
*She stated her supervisor had not informed her if the patient had been on isolation.
*She was unsure of the name of the chemicals she would have used to disinfect the procedure room.
*She did not know about the chemical or how long (contact time) equipment surfaces needed to stay wet in order for the disinfectant to have been effective.
*There were no signs posted outside the room to inform staff about the type of isolation or what PPE should have been worn prior to entering the room.

After the patient's PICC procedure he was taken to the CT room. Observation in the CT Department and the room patient 11 was being scanned in revealed there were no isolation signs posted informing staff of the appropriate isolation protocols or the type of isolation the patient was on.

Interview on 3/11/15 at 11:37 a.m. with the environmental director revealed:
*The only reason ES staff were sent to the radiology departments was to clean a room after an isolation patient had been treated.
*The staff in the Specials Department and in the CT department should have posted isolation signs according to the infection the patient had.
*The isolation signs would have informed environmental services what type of isolation and what type of PPE should have been worn by the staff.






6. Observation and interview on 3/9/15 at 3:35 p.m. with physical therapist C on the medical floor revealed:
*He would use the foam hand sanitizer outside the patient's room prior to entering and when he left the patient's room.
*He would wash his hands with soap and water for every two to three patients that he would care for.

7. Interview on 3/9/15 at 3:55 p.m. with RN B on the neuro-surgical floor regarding isolation practices revealed:
*She was unsure as to what she would have done if a family member or a visitor of an isolation patient would not adhere to the isolation precautions.
*She stated you could not refuse to let the family visit the patient.

8. Review of patient 5's medical record revealed:
*She had been admitted on [DATE].
*She was discharged on [DATE].
*Her diagnoses and symptoms included:
-Seizures.
-Renal (kidney) disease.
-Diarrhea.
*She had a history (July 2014) of [DIAGNOSES REDACTED].
*On 2/14/15 she had a positive confirmation of [DIAGNOSES REDACTED] in her feces (stool).
*There was no documentation found in her medical record that isolation precautions had been implemented on her admission to the hospital due to her symptoms of [DIAGNOSES REDACTED]
*There was no documentation until 2/16/15 that was two days after her positive lab results on 2/14/15 and was three days after her initial admission to the hospital.

Review of patient 5's 2/14/15 Specimen Inquiry sheet revealed:
*She was positive for [DIAGNOSES REDACTED].
*There was documentation the lab personnel had called a nurse on the floor where the patient was residing on 2/14/15 at 1559 (3:59 p.m.).

Review of patient 5's nursing assessments from 2/13/15 through 2/16/15 revealed:
*There had been no documentation of the positive [DIAGNOSES REDACTED] confirmation from the lab.
*There was no documentation until 2/16/15 regarding the positive [DIAGNOSES REDACTED] findings, and that documentation was from the infection control staff.

Review of patient 5's nurses notes documentation on 2/16/15 at 10:20 a.m. revealed "Reviewing chart per Nursing Assessment request. Patient should be placed on Contact Precautions (CD) for Clostridium Difficile. Please inform the doctor that the patient has been placed on these precautions. Continue to follow Standard Precautions and wash hands with running water and soap."

Review of patient 5's 2/14/15 plan of care revealed there was no documentation for the following:
-Her positive history of [DIAGNOSES REDACTED] in July 2014.
-Her current positive lab specimen for [DIAGNOSES REDACTED] on 2/14/15.
-Any interventions that would have been put in place including contact precautions.

Interview on 3/9/15 at 3:15 p.m. with RN U during patient 5's chart review revealed:
*She was on contact precautions that meant anyone entering the room should have worn a gown and gloves.
*She was unsure if any teaching had been completed for the patient or her family regarding the [DIAGNOSES REDACTED].
*The room was monitored by the staff at the nurses station.
*The patient was confused at times.
*She was admitted with seizures and diarrhea.
*The patient had a history of [DIAGNOSES REDACTED] in July 2014.
*She was confirmed with positive [DIAGNOSES REDACTED] on 2/14/15.

Interview on 3/11/15 at 9:20 a.m. with the director of professional services and infection control licensed practical nurse (LPN) R regarding the above findings revealed:
*Lab would notify the patient's nurse per telephone.
*The nurse would then implement the appropriate isolation precautions for that patient.
*LPN R worked Monday through Friday during the week.
*The positive infection was noted on 2/13/15, so she would not chart on that patient until Monday (2/16/15) when she returned to work.
*They both agreed after review of the chart there had been no isolation precautions implemented on the patient with a positive [DIAGNOSES REDACTED] until two days after the infection was confirmed by the lab.

Interview on 3/11/15 at 10:35 a.m. with the medical director of infection control, director of infection control S, infection control LPN R, and infection control nurse LPN F revealed:
*Infection control was available twenty-four hours a day and seven days a week for any questions the staff might have had regarding infection control.
*The staff had in certain circumstance restricted visitors and/or family from patients on isolation precautions. Those visitors or family members had been non-compliant (had not followed the rules) with the infection control precautions for those patients.
*The staff had notified security when visitors or family members had been non-compliant and had those individuals removed from the facility.
*There was a large TB population, and some of those visitors had not wanted to use PPE.
*They all felt as though there was no legal ramifications the hospital could have taken if those visitors or family members had refused to use PPE.
*They all agreed that all patients have the same rights.
*The patients, family members, and visitors should have been protected from any exposure to infectious diseases.
*All patients have the right to a safe environment while hospitalized .
*They all agreed that policy and procedures were not being followed by all the hospital staff regarding isolation precautions.
*The infection control staff were having difficulty getting management to cooperate with infection control practices and issues.
*They had felt as though past management had not supported ramifications for non-compliance by the hospital staff with infection control issues.
*There had been no TB education provided after the exposure was identified. The infection control team had spoken to management but had not provided the hospital wide re-education on TB.
*They agreed the positive TB patient 9 had not been placed in isolation in a timely manner. There had been exposure to staff because of the lack of appropriate isolation precautions.
*They agreed the documentation needed improvement regarding implemented isolation precautions.
*They confirmed the obligation of the hospital was to have kept patients, visitors, and staff safe.





9. Observation on 03/09/15 at 3:03 p.m. revealed two visitors in rooms 1005 and 1027 had not put on PPE. The isolation patient in room 1005 was on Multidrug Resistant (MDR) precautions. Instructions posted outside the room indicated staff and visitors were to wear gloves, a mask, and a gown. The isolation patient in room 1027 was on droplet precautions. The sign outside the room indicated employees and visitors were to wear a mask while in the room.

Interview with employee P at the time of the above observation revealed visitors had been instructed to wear the PPE, but if they refused there was nothing the facility staff could have done. Interview on 03/09/15 at 3:04 p.m. with the employee Q confirmed employee P's statement.





10. Observation on 3/9/15 at 3:45 p.m. of room 309 revealed:
*Droplet and contact isolation precautions signage was posted outside the door.
*A male visitor was holding patient 3 inside the room.
*The male visitor was not wearing any PPE.

Interview at the time of the above observation with the director of professional practice revealed the visitor should have worn PPE.

Interview on 3/11/15 at 9:25 a.m. with the women and children services director revealed:
*Patients' family members were supposed to gown and glove.
*The provider struggled getting family members to wear PPE.
*She was not aware of any provider policy that required family members to wear PPE.

Review of the provider's September 2014 General Information for Isolation Precautions policy revealed all visitors to an isolation room should have followed the guidelines for that type of isolation.

11. Review of the above listed patients' medical records revealed only patients 9 and 13 had documentation of specific isolation education for the patient and their visitors.

Review of the provider's October 2014 Placing a Patient in Isolation policy revealed:
*The healthcare provider would explain the purpose of isolation to the patient and their support person.
*A isolation handout would be made available.

Interview on 3/11/15 at 9:15 a.m. with the director of risk and safety revealed education specific to isolation was not documented in the patient's medical record.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, interview, and policy review, the provider failed to ensure:
*Hand hygiene was performed during one of one observed PICC ([peripherally inserted central catheter] the catheter is placed in the vein that carries unoxygenated blood from the upper half of the body to the upper right side of the heart) line flushing for patient 11 by one of one registered nurse (RN) B.
*Appropriate disinfection of one of one blood glucose meter after the meter was used for one of one patient (19) who had methycillin resistant staphylococcus auerus and influenza A by one of one patient care technician (PCT) N.
Findings include:

1. Observation and interview on 3/10/15 at 9:00 a.m. with RN J during a PICC line flush with patient 11 revealed she:
*Had been employed nine months with the provider.
*Placed the appropriate mask over her nose and mouth.
*Washed her hands prior to entering the patients room.
*Flushed the patient's PICC line with normal saline without wearing gloves.
*Left the room and washed her hands after the procedure.

Interview with director of the medical floor X immediately following the above observation revealed she did not believe staff needed to wear gloves during the flushing of a patient's PICC line.

Review of the provider's October 2014 Central Venous Access Devices policy revealed the nurse should wash hands and place nonsterile gloves on hands prior to flushing the PICC line.

2. Observation on 3/10/15 at 8:25 a.m. with PCT N after the blood glucose had been obtained from patient 11 revealed:
*She wiped the blood glucose meter with the disinfectant Steriplex.
*She then immediately placed the blood glucose meter in the docking station setting on top of the nurses station.

Interview on 3/10/15 at 8:35 a.m. with RN O and the director of professional services regarding the above observation with PCT N revealed:
*The Steriplex needed to stay wet on the surface of the blood glucose meter for five minutes.
*They both agreed that had not been done by PCT N.

Review of the provider's January 2015 Nova StatStrip Glucose Meter policy revealed:
*Each meter should have been disinfected prior to use for another patient.
*Each meter should have been wiped down with a germicidal wipe as approved by the laboratory on all exterior surfaces.
*Squeeze the germicidal wipes to remove excess liquid and carefully wipe the meter.
*Immediately follow with a water-dampened cloth or paper towel to remove all cleaning residue.
*Dry thoroughly with a soft cloth or lint-free tissue.

Interview on 3/11/15 at 10:00 a.m. with infection control director S regarding the disinfection of the blood glucose meter revealed:
*Contact time with the Steriplex was five minutes.
*The glucose meter should not have been placed back into the docking station immediately after cleaning the machine with Steriplex.
*She agreed the policy and procedure did not reflect the procedure that was done by PCT N.
*The teaching for all staff included Steriplex would have been used to disinfect the glucose meter. Steriplex needed a five minute contact time for a complete kill of Clostridium difficile spores, bacteria, viruses, and fungi.