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Based on policy/procedure review, record review, and interview, the hospital failed to ensure drugs and biologicals were administered in accordance with orders of the practitioners responsible for the patient's care. This deficient practice is evidenced by failure of the nursing staff to apply Nystatin topically as ordered 8 times for 1 (#5) of 5 sampled patients.

Findings:


Review of Patient #5's medical record revealed an order dated 10/22/19 at 2:00 p.m. for Nystatin Cream topical BID.

Review of Patient #5's Treatment Administration Record revealed the medication Nystatin Cream topical BID and PRN. The scheduled administration times were 9:00 a.m. and 9:00 p.m. Initials indicating the dose had been given were omitted next to the 9:00 a.m. time on 12/1/19, 12/3/19 and 12/5/19. The 9:00 p.m. dose was not initialed as having been given on 12/1/19, 12/2/19, 12/3/19, 12/4/19 and 12/5/19.

In an interview on 12/9/19 at 1:00 p.m. with S7LPN, she said she administers medications at the hospital. She said if a medication is not initialed on the treatment record that would indicate it was not given. After looking through Patient #5's medical record, she verified she could not find any notes when the medication was held or given.

Based on record review and interview, the hospital failed to ensure each patient had a medical H&P examination completed and documented no more than 30 days before or 24 hours after admission. This deficient practice is evidenced by having no H&P in the medical record for 1(#4) of 5 patients sampled.

Findings:

Review of Patient #4's medical record revealed she was admitted to the hospital on 10/25/19.

Review of the hospital policy titled Timely Entries in Medical Records revealed the following:
Upon admission to the hospital, a history and physical examination must be performed by the attending physician and shall contain all pertinent findings and an assessment of all body systems. This report must be hand written or dictated, transcribed and placed in the medical record within 96 hours of admission.

Review of Patient #4's medical record on 12/9/19 at 2:00 p.m. revealed no history and physical was documented in the medical record.

In an interview on 12/9/19 at 2:15 p.m. with S5Staff, she verified there was no history and physical in Patient #4's medical record but there should have been within 24 hours of admission. S5Staff also verified the hospital's policy allowing 96 hours was incorrect.

Based on record review, observation, and interview, the hospital failed to ensure a system for controlling infections and communicable diseases of patients and personnel was established. This deficient practice was evidenced by:
1. failure to ensure contaminated patient linens were laundered following acceptable infection control practices for disinfection during laundering. There were 3 current patients on isolation precautions (#1, #2, #3). This deficient practice had the potential to affect all 7 current patients receiving care in the hospital at the time of the survey; and

2. failure to ensure staff members followed contact isolation precautions in 1 (#3) of 3 (#1, #2, #3) patients rooms with isolation precautions; and

3. failure to ensure urine collection from patient Foley catheter bags was completed without spillage of urine on the floor for 1(#5) of 1 sampled patients observed with a Foley catheter from a total patient sample of 5 ( #1-#5).

Findings:

1. Failure to ensure contaminated patient linens were laundered following acceptable infection control practices for disinfection during laundering.

Review of the CDC Guidelines for Environmental Infection Control in Health-Care Facilities (2003) revealed the following, in part:
1. General Information: Laundry in a health-care facility may include bed sheets and blankets, towels, personal clothing, patient apparel, uniforms, scrub suits, gowns, and drapes for surgical procedures. Contaminated textiles and fabrics in health-care facilities can be a source of substantial numbers of pathogenic microorganisms. Existing control measures (e.g., standard precautions) are effective in reducing the risk of disease transmission to patients and staff. Therefore, use of current control measures should be continued to minimize the contribution of contaminated laundry to the incidence of health-care associated infections. The control measures described in this section of the guideline are based on principles of hygiene, common sense, and consensus guidance; they pertain to laundry services utilized by health-care facilities, either in-house or contract, rather than to laundry done in the home.
2. Epidemiology and General Aspects of Infection Control: OSHA defines contaminated laundry as "laundry which has been soiled with blood or other potentially infectious materials or may contain sharps." Contaminated textiles and fabrics often contain high numbers of microorganisms from body substances, including blood, skin, stool, urine, vomitus, and other body tissues and fluids. When textiles are heavily contaminated with potentially infective body substances, they can contain bacterial loads of 106 -108 CFU/100 cm2 of fabric. Disease transmission attributed to health-care laundry has involved contaminated fabrics that were handled inappropriately (i.e., the shaking of soiled linens). Bacteria (Salmonella spp., Bacillus cereus), viruses (hepatitis B virus [HBV]), fungi (Microsporum canis), and ectoparasites (scabies) presumably have been transmitted from contaminated textiles and fabrics to workers via a. direct contact or b. aerosols of contaminated lint generated from sorting and handling contaminated textiles. Through a combination of soil removal, pathogen removal, and pathogen inactivation, contaminated laundry can be rendered hygienically clean. Hygienically clean laundry carries negligible risk to health-care workers and patients, provided that the clean textiles, fabric, and clothing are not inadvertently contaminated before use. The antimicrobial action of the laundering process results from a combination of mechanical, thermal, and chemical factors. Dilution and agitation in water remove substantial quantities of microorganisms. Soaps and detergents function to suspend soils and also exhibit some microbiocidal properties. Hot water provides an effective means of destroying microorganisms. A temperature of at least 160°F (71°C) for a minimum of 25 minutes is commonly recommended for hot-water washing. Water of this temperature can be provided by steam jet or separate booster heater. The use of chlorine bleach assures an extra margin of safety. A total available chlorine residual of 50-150 ppm is usually achieved during the bleach cycle. Chlorine bleach becomes activated at water temperatures of 135°F-145°F (57.2°C-62.7°C). The last of the series of rinse cycles is the addition of a mild acid (i.e., sour) to neutralize any alkalinity in the water supply, soap, or detergent. The rapid shift in pH from approximately 12 to 5 is an effective means to inactivate some microorganisms. Effective removal of residual alkali from fabrics is an important measure in reducing the risk for skin reactions among patients. Chlorine bleach is an economical, broad-spectrum chemical germicide that enhances the effectiveness of the laundering process. Oxygen-based bleach and detergents used in health-care settings should be registered by EPA to ensure adequate disinfection of laundry.

Review of the hospital census, presented as current by the charge nurse, revealed there were seven total patients with three of those patients in isolation. Patient #1 was in contact isolation for MRSA infection (wound); Patient #2 was in isolation due to Pseudomonas infection (blood and wound); and Patient #3 was in isolation due to MRSA (blood) bacteremia.

An observation of the laundry room was conducted on 12/6/19 at 11:35 a.m. During the observation soiled patient blankets and sheets were noted to be piled on the floor in front of the washing machine. The soiled patient linens were not contained in any type of linen bag or red bag. There was a very strong odor of urine permeating the room. There was no way to determine which patients' linens had been collected since the linens were not bagged or labeled.

Further observation of the laundry room revealed cleaning chemicals were in wall mounted containers adjacent to the washing machine and dryer. Tubing was observed coming from the containers for dispensing the chemicals. The following chemicals were noted:
a. Signet Neutral Floor Cleaner;
b. Signet Heavy Duty Non-acid washroom cleaner/disinfectant;
c. Signet Glass and Multi-surface cleaner; and
d. Signet Neutral Disinfectant.
None of the chemicals observed were for laundry use as they were labeled for cleaning surfaces, floors, and glass.
Additional observation revealed a 2.2 Liter bottle of Extra laundry detergent (non-disinfectant, not for hospital use) was located on the top of the dryer.

In an interview on 12/6/19 at 11:16 a.m. with S5Staff, she confirmed, during the observation, that the above referenced chemicals were to be used for housekeeping and not for use for laundering linens. She indicated the washer and dryer were not supposed to be used for laundering patient linens because they have an agreement with a linen service for laundering of the hospitals linens.

In an interview on 12/6/19 at 11:18 a.m. with S4CNA, she reported she had been washing patient linens because she was "running low" on fitted sheets. S4CNA indicated she used a cupful of the Extra detergent and a capful of the neutral disinfectant and a capful of the heavy duty non-acid washroom cleaner (disinfectant for surfaces) to wash patient linens. She confirmed she did not log the temperature of the water when she ran loads of patient linens and she also confirmed there were no chemical logs of any kind. She indicated she wiped out the washer and dryer with the disinfectant wipes between loads. She reported the "nurse" had trained her to wash and dry patient laundry. She did not provide the surveyor with a name of the "nurse" who had trained her.

In an interview on 12/6/19 at 11:20 a.m. with S3Owner, he indicated the washer and dryer were not to be used for laundering patient linens.

In an interview on 12/6/19 at 11:50 a.m. with S5Staff, she reported the reason they had a washer and dryer was because the patients had used the washer and dryer for OT rehabilitation when they were a rehabilitation hospital. She said when they were no longer a rehabilitation hospital the infection control nurse told them they could no longer use the washer and dryer for laundering patient linens/patient items. She reported all 3 of the last DONs had no problem with the washer and dryer being used for washing patient linens. She confirmed she had looked for policies regarding infection control practices for laundering/disinfecting patient linens and disinfecting the washer and dryer between uses. S5Staff confirmed there were no polices under Infection Control, Housekeeping, or Nursing regarding infection control practices for laundering/disinfecting patient linens and disinfecting the washer and dryer between uses. She further confirmed there were no temperature or chemical logs being kept by staff when they were washing patient linens.

2. Failure to ensure staff members followed contact isolation precautions.

Review of the hospital policy titled Isolation Precautions revealed the following:
Contact Precautions: In addition to Standard Precautions, use Contact Precautions, for specified patients known or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct contact with the patient or indirect contact with environmental surfaces or patient care items in the patient's environment.
3. Gloves and Hand Hygiene: In addition to wearing a gown as outlined under Standard Precautions, wear clean, nonsterile gloves when entering a room.

Review of Patient #3's medical record revealed he was admitted on 11/19/19 with Septicemia and Bacteremia.

Observation on 12/9/19 at 1:20 p.m. revealed S8Housekeeping cleaning Patient #3's room. She was not wearing a gown. S8Housekeeping then exited the room and did not remove her gloves. She then touched several items on the cleaning cart and started mopping the hallway while wearing the gloves.

In an interview on 12/9/19 at 1:25 p.m. with S7LPN , she said Patient #3 was on contact precautions because he had MRSA in his blood.

In an interview on 12/9/19 at 1:30 p.m. with S9RN, she said contact precautions meant wearing gloves and a gown each time you entered the patient's room.

In an observation on 12/9/19 at 1:36 p.m., S10CNA was observed in Patient #3's room leaning on his bedside table with her forearms. S10CNA was not wearing a gown or gloves. She then left Patient #3's room and did not sanitize or wash her hands.


3. Failure to ensure urine collection from patient Foley catheter bags was completed without spillage of urine on the floor.

On 12/6/19 at 7:50 a.m. an observations was made of Patient #5's room. Patient #5 was observed to have a Foley catheter hanging on the side of her bed. Further observation revealed a large puddle of fluid under the foot of the patient's bed. Additional observation revealed an electrical cord trailing through the puddle of fluid.

In an interview on 12/6/19 at 8:20 a.m., conducted during an observation of Patient #5, S6LPN confirmed there was pooled fluid under the patient's bed with an electrical extension cord running through it. She indicated the pooled fluid was urine and explained someone must have drained the patient's Foley catheter and had failed to close the drainage port.