HospitalInspections.org

Based on document review and staff interview it was determined the hospital failed to fully inform an extended care facility of a Carbapenem-resistant Enterobacteriaceae (CRE) bacterial infection in a patient who was sent there in transfer. Additionally, the hospital failed to ensure the extended care facility was provided with a complete explanation of the significance of a CRE infection and the necessary precautions that may be needed to mitigate the spread of this infection to other residents. When receiving facilities are not made fully aware of a multiple drug resistant bacteria in a patients urine can result in the spread of this infection to other patients or staff.

Findings include:

The 2012 Center for disease control guidance for Carbapenem-resistant Enterobacteriaceae states that CRE are a serious threat to public health. Infections with CRE are difficult and in some cases impossible to treat and have been associated with mortality rates up to 50%. CDC infection control recommendations include contact precautions for patients with CRE and whenever possible, dedicated rooms, equipment and staff to CRE patients. The state of West Virginia has recently added CRE as being a reportable infectious disease.

Review of medical record for patient #1 revealed the patient resided in an extended care facility and was sent to the Emergency Department (ED) on 5/30/13 for evaluation and treatment. While in the ED a urinalysis with culture and sensitivity was obtained prior to admission. On 6/2/13 the laboratory reported the urine had klebsiella (100,000 colonies per milliliter) which was a Carbapenem-resistant Enterobacteriaceae (CRE). The infection preventionist was notified and the patient was placed in strict contact isolation. This urine specimen was sent to an outside laboratory for confirmation of the CRE. The infectious disease physician was consulted and diagnosed the patient with Carbapenem resistant klebsiella.

On 6/6/13 the patient was discharged back to an extended care facility. The medical record lacked evidence the receiving facility was notified the patient had a CRE in the urine and any special infection control measures that were used while the patient was in the hospital. Additionally, the medical record lacked the transfer form that contained the medical information that was sent to the receiving facility upon the patients discharge.

The state agency was able to obtain a copy of this transfer form from the extended care fallibility. The transfer form did not contain any information about the klebsiella in the urine which was Carbapenem resistant (CRE). Also, there was no information about the patient being in strict isolation while hospitalized.

The Registered Nurse (RN 1), who discharged the patient, was interviewed on 8/21/13 at 0930 hours. He stated he had called the extended care facility about the patient's discharge and told the nurse there the patient had tested positive for a CRE. He agreed there was no documentation in the medical record or transfer form about the CRE in the urine or the patient being in strict isolation while hospitalized.