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.

SSM HEALTH ST MARY'S HOSPITAL - MADISON 700 SOUTH PARK ST MADISON, WI 53715 March 22, 2016
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, record review and interview, the facility staff 1) failed to perform hand hygiene per policy in 3 of 3 patient care observations (Patient #6, Patient #7, Patient #8); 2) failed to provide infection control education relevant to the population in 1 of 1 Neonatal Intensive Care Unit; and 3) failed to surveille for hospital-acquired infections per accepted standards of practice in 1 of 1 Neonatal Intensive Care Unit. This has the potential to affect all 26 patients receiving care in the Neonatal Intensive Care Unit at the time of the survey.

Findings:

1) Facility policy "Hand Hygiene" dated 10/16/2013 states: "3. It is required that all staff follow these specific indications for hand washing and hand antisepsis: Use alcohol hand rub or wash with soap and water: -before having direct contact with patients; -before medication preparation and administration; -after direct contact with patient's intact skin; -after contact with inanimate objects in the immediate vicinity of the patient; -after removing gloves or other personal protective equipment..."

On 3/22/2016 at 9:40 AM, RN D performed an assessment on Patient #6 in room #2519 in the Neonatal Intensive Care Unit (NICU). After the assessment, RN D walked to the other side of the room wearing gloves and proceeded to use an alcohol-based antiseptic on the gloves then returned to the patient's bedside to continue performing cares. At 9:49 AM RN D again applied the alcohol based antiseptic to hands while wearing gloves.

On 3/22/2016 at 10:00 AM, RN E obtained a blood sample from Patient #7 in room #2502 in the NICU. After obtaining the blood, RN E used the bedside computer without changing gloves and performing hand hygiene. After using the computer, RN E removed the gloves and, without performing hand hygiene, obtained clean supplies from the cabinet in the room and brought the clean supplies into Patient #7's isolette. RN E then left the room with the blood sample without performing hand hygiene.

On 3/22/2016 at 10:40 AM RN F applied an alcohol-based antiseptic to gloved hands in Patient #8's room, #2509 in the NICU. At 10:50 AM, RN F changed Patient #8's diaper then proceeded to change gloves without performing hand hygiene before preparing Patient #8's feeding. RN F again changed gloves without performing hand hygiene at 10:55 AM.

During an interview on 3/22/2016 at 1:00 PM with Nurse Epidemiologists B and C, Nurse C stated each department has a "hand hygiene champion" who does hand hygiene audits on the unit. Per C, the NICU department's hand hygiene audits have been at 100% every month for over 7 months. Review of the hand hygiene audit form asks: "HH [Hand Hygiene] before patient contact? HH after patient contact or glove removal? HH observed during a procedure." Applicable responses include: "According to standard; Sub-standard use; No use; NA." Nurse Epidemiologists B and C stated that the above observations would fall into the "sub-standard use" category for the hand hygiene audit. Nurse B stated it is the facility's policy to perform hand hygiene after removing gloves and stated the use of alcohol based antiseptic on gloves is not acceptable practice.

2) Review of NICU staff personnel files do not include any infection control education that is specific to the NICU department or the neonate population. During an interview on 3/22/2015 at 2:30 PM, Manager A stated all staff received the facility's "Severe Sepsis/Septic Shock" training but the training is related to patients 18 years and older and "isn't applicable" to neonates.

3) On 3/22/2016 at 11:40 AM, Manager A stated the NICU follows the American Academy of Pediatrics and CDC Guidelines for standards of practice. The American Academy of Pediatrics "Guidelines for Perinatal Care, 7th Edition" recommends the following under Prevention of Health-Care Associated Pneumonia "Infection and microbiologic surveillance--Surveillance for health care-associated pneumonia should be performed to determine trends and help identify outbreaks or other problems."

During an interview on 3/22/2016 at 1:00 PM, Nurse Epidemiologist B stated the facility only tracks Central Line-Assocated Blood Stream Infections in the NICU and does not perform any other type of routine surveillance for hospital-acquired infections.