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.

WILLOUGH AT NAPLES, THE 9001 TAMIAMI TRAIL EAST NAPLES, FL 34113 Nov. 1, 2013
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based upon observation, interview and record review the facility failed to ensure the hospital environment is maintained in a clean and safe condition for 4 (rooms 203, 204, 214, 105) of 24 patient rooms affecting 2 (Patient #4 and #6) and potentially affecting many other patients.

The findings include:

During initial facility tour on 10/30/13, the surveyor observed dead bedbugs in room 203 and 204. At 6:24 p.m. on the same day, the surveyor observed ants in room 104 and in the "noisy social room" on the 100-hall.

In an interview about bedbug treatment on 10/30/13 at 2:30 p.m., the Director of Nursing (DON) and Chief Operating Officer (COO) said that they will close the room off for 3 hours after treatment then allow the residents to return to the room once pest control says it is okay.

In an interview on 10/30/13 at 3:30 p.m., the Environmental Supervisor with the Department of Health in Collier County said multiple dead bedbugs were found in room 204 during her inspection earlier that day.

Review of records revealed Patient #4 was admitted [DATE]. The patient complained about bedbugs on admission. The patient's complaint of bedbugs and itching on 10/8/13. Progress note of 10/9/13 documented request to change room. Progress note of 10/17/13 included move to a new room. A skin assessment was not done.
In an interview on 10/30/13 at 4:05 p.m., Patient #4 reported no further bedbug issues after the move.

Review of records revealed Patient #6 was admitted [DATE] to room 105. Progress note of 10/12/13, documented complaint of itching. Progress note of 10/17/13, documented complaints of bedbug bites and itching. On 10/18/13, the patient moved to a new room. A skin assessment was not done. Room 105 was not treated but left unused. On 10/20/13, the patient was to move back to room 105 but refused.
In an interview on 10/30/13 at 6:00 p.m., Patient #6 said a physician assistant said that he could not identify the bites on the first day; then on the second day they told him they were bedbugs. The patient said they cleaned the room, but did not clean his clothes.

The report of inspection dated 10/31/13, by Environmental Specialist with the Department of Agriculture and Consumer Services - Bureau of Entomology and Pest Control included, "We started with room 203. We found a few dead bedbugs and a live one on the mattress on the bed on the right, closest to the window."

Review of Pharmacy & Therapeutic Infection Control Meeting dated 10/22/13 revealed acknowledgement of bedbugs in room 214. There was no mention of the bedbugs found in any other rooms. The report stated all patients were moved to a vacant room on the 200 unit. Nursing and Maintenance had no additional issues.

Review of facility policy and procedure INF-1:0083 Bed Bug Control (effective 11/15/11) revealed the procedure including:
"1. If a patient or staff member reports a suspected infestation of bedbugs or suspected bedbug bites, the following must be done: Refer the client to the Nurse and/or Physician for confirmation of bedbug bites,...
2. Notify Maintenance/Facilities Department to inspect the area(s) of concern, who will notify the Hospital's licensed exterminator. The exterminator will inspect the affected room(s) and/or make a determination as to whether or not the bedbugs exist...
3. Once an infestation is confirmed by the licensed exterminator, the following protocol will be adhered to: Alert administration and nursing of the infestation; Using Contact Isolation Precautions (Gloves, Gowns, Shoe Covers), seal all bedding and clothing in CLEAR plastic bags; and
4. Clothing will be washed in hottest possible temperature. Bedding will be changed and washed in commercial machines at The Willough.
Using Contact Isolation Precautions, (Gowns/Gloves/Shoe Covers) Housekeeping will strip the bed(s) and launder all sheets, pillowcases, mattress pads and blankets in the hottest water possible for the fabric being laundered. Dry items for at least one (1) hour in the hottest cycle possible for the fabric being dried. Please make sure that commercial washer/dryer is filled ONLY to 3/4 capacity. DO NOT OVERLOAD.
Housekeeping will launder all clothing and fabrics (or dry clean) in the hottest water possible for the fabric. Dry for at least one (1) hour in the hottest dryer cycle possible for the fabric...
Box springs and mattresses MUST be removed from the frame and stood against a wall.
5. Once patient bedding and personal belongings are addressed, patients will be assigned new rooms.
6. Commercial and licensed exterminator will treat all affected bedroom(s) and area(s). The affected, treated areas will then be sealed for a minimum of 3 hours, per licensed exterminator.
After a minimum of 3 hours, vacuum all infested rooms. Besides the floor, also vacuum mattresses, box springs, couches, chairs, closets and closet shelves, shoes, and inside dresser drawer drawers and bedside table drawers. After vacuuming an infested area, flea powder should always be spread on the floor and vacuumed up to kill any bugs inside the vacuum cleaner. Vacuum bags should be immediately sealed in plastic bags and thrown away. All beds, bed frames and mattresses will be washed with disinfectant detergent
7. The rooms will be approved by a licensed pest controller before being occupied by patients.
8. The hospital's Chief Operating Officer (COO) will keep dates, timelines and exterminator reports on all incidents of suspected bedbug occurrences..."

In an interview on 10/31/13 at 10:30 a.m., the facility Program Director stated that from October 2012 to current date, there were no complaints of bedbugs or pests.

Review of pest control invoice dated 9/19/13 described service for that day as "Treat for bedbug eradication in Room #214."
Review of 200 Wing Census for 9/19/13 revealed room 214 had been occupied by Patient #15, #16 and #17. The census sheet noted each of the 3 patients "moved to 204."

Review of pest control invoice dated 10/7/13 described service for that day as "Treat for bedbug eradication in Room #201. Inspected #201 (N/C)."

In an phone interview on 10/31/13 at 2:30 p.m., the licensed pest control person said after treating, he seals up the room and never comes back for a follow-up. He expects the facility to clean the room in accordance to the policy and procedure. With his chemicals he cannot guarantee it kills eggs. He was unsure how long the eggs last. The residual can disappear after being mopped.

During a second facility tour on 10/31/13 at 12:15 p.m., with the Director of Maintenance, the surveyor observed live and dead bedbugs in room 203. This room had been treated by pest control the night before.
In room 214 the surveyor observed dead bedbugs, black dots and white cylindrical moist squishy egg-like objects were found on mattresses. This room was originally treated by pest control in September 2013. Tiny white eggs and black dots on the mattress are a sign of bedbug infestation (per EPA website http://www.epa.gov/oppfead1/Publications/bedbug-tips.pdf).
In room 204, the surveyor found dead bedbugs and other dead insects and debris in between the mattress and boxspring. He observed numerous dead ants on the window sill.
In room 105, the surveyor observed dried brown substance running down wall in corner. He observed debris including a dead bedbug in the corner underneath the dresser. Various debris was under bed 2. The baseboards were covered in dust and debris.

In an phone interview on 10/31/13 at 2:30 p.m., the licensed pest control person said after treating, he seals up the room and never comes back for a follow-up. He expects the facility to clean the room in accordance to the policy and procedure. With his chemicals he cannot guarantee it kills eggs. He was unsure how long the eggs last. The residual can disappear after being mopped.

In an interview on 10/31/13 at about 3:00 p.m., the COO states that they were listening to the exterminator. He acknowledged that the policy was not followed and that the licensed pest control should have re-evaluated the rooms to confirm no live bedbugs.

Review of infection control manual reveals tracking of infections; however bedbugs were not included in the infection control.
In an interview on 10/31/13 at 3:55 p.m., the Quality Assurance (QA)/Program Improvement (PI) Coordinator said there is not any QA of any housekeeping done at this time to verify the rooms are cleaned.

During a third facility tour on 11/1/13, in room 214 the surveyor observed a hard white brittle substance attached to the bottom of the boxspring of bed 3. There were white moist egg-like objects and black dots found on the box spring of bed 2.
In room 105, dust and debris remained underneath the dressers and bed. There were brown stains on the bathroom wall.
In the "noisy social room" dead ants remained on the window sill.

In an interview on 11/1/13 at 10:10 a.m., housekeeping Staff #2 and #3 discussed bed bug procedures. They said they bag any bedbug clothes in special (clear water-soluble) bags. Clothes are then washed in hot water. Clothes are dried depending on type. Settings are for 40-50 minutes for some, 20-25 minutes for others. Surveyor observed that dryer time/temp is determined by setting the clothing type. Regarding room cleaning, Staff #2 said floors are tile, so they don't vacuum. She said maintenance vacuums the bedframes & mattresses.

On 11/1/13 at 11:05 a.m., the surveyor and the QA/PI Coordinator observed the cleaning of room 204. The housekeeper then sprayed the bed and mattress with Tilex disinfectant and wiped off in less than a minute (manufacturer label directs to let stand 5 minutes). The pillow was not wiped down. Clean linen placed on the pillow. At no point was the bottom of the mattress wiped down or the boxspring wiped down. The housekeeper stated she does not clean in between the mattress. It is too heavy.

During a third facility tour on 11/1/13 at about 11:30 a.m., in room 214 the surveyor observed a hard white brittle substance attached to the bottom of the boxspring of bed 3. There were white moist egg-like objects and black dots found on the boxspring of bed 2.
In room 105, dust and debris remained underneath the dressers and bed. There were brown stains on the bathroom wall.
In the "noisy social room" dead ants remained on the window sill.

In an interview on 11/1/13 at 12:25 p.m., the Director of Environmental Services (DES) discussed bedbug procedures. She said clothes are washed and dryer is set on "highest heat for about 25-30 minutes." The clean laundry is returned to nurses' station. "We clean after maintenance tells us it's OK. Between 4 and 6 hours after exterminator. We go in and clean the whole room. Lysol wipes on top and bottom of mattress (to flip mattress over - we call maintenance). If the bed has a frame, use wipes on ridges of the frames. Then replace with new bedding and sheets."

In an interview on 11/1/13 at 1:45 p.m., the Director of Maintenance stated his staff rarely flips any mattresses and it is "not very often." He stated that they do help move the furniture for housekeeping when they are requested. He said maintenance does not do any vacuuming in the rooms, only ducts and the air vents.