HospitalInspections.org

21521

Based on policy review, interview, observation, and clinical record review, the facility failed to ensure its policies regarding isolation for Patient #9 and #8 were followed, and regarding hand washing for Patient #3 were followed. Patient #9 with no known history of C. difficile shared a room with Patient #8 who did. Patient #9, with a history of VRE (vancomycin-resistant enterococcus infection) shared a room with Patient #8 who did not have a history of VRE. The sample size was ten patients, the census was 105 patients.

Findings:

The clinical record review for Patient #9 was completed on 03/15/11. The clinical record review revealed the patient was admitted to the hospital on 09/25/10 with a diagnosis of pneumonia. The clinical record review revealed a history and physical dictated on 09/26/10 that stated the 84-year-old patient had a past medical history of dementia, fibrotic lung disease, hypertension, depression, "severe" protein-calorie malnutrition, and osteoporosis. The history and physical stated in the hospitalization that immediately preceded the admission to the facility, he/she had developed a vancomycin-resistant enterococcus urinary tract infection and pneumonia. The history and physical stated the current antibiotic regimen would be maintained to treat the infections.

The clinical record review revealed a physician's order dated 09/25/10 at 5:00 P.M. to place the patient in contact isolation (for vancomycin-resistant enterococcus urinary tract infection).

The clinical record review revealed on 09/25/10 the patient was placed in room 58.

The clinical record review revealed a physician's progress note dated 09/27/10 that stated the patient's stool was loose and check for C. difficile "just to be safe" and "probably worsened with (antibiotics)."

The clinical record review revealed a final laboratory result dated 09/28/10 that stated the patient's stool was negative for C. difficile.

The clinical record review revealed on 09/28/10 the patient was placed in room 44A.

The clinical record review revealed a final laboratory result dated 10/16/10 that stated the patient's stool was positive for C. difficile.

The clinical record review revealed a physician's progress note dated 10/16/10 that stated the patient had C. difficile and to start an antibiotic (flagyl).

The clinical record review revealed a physician's order dated 10/16/10 that stated to start the antibiotic.

The clinical record review revealed a final laboratory result dated 10/31/10 that stated the patient's stool was positive for C. difficile.

The clinical record review revealed a discharge summary dated 11/05/10 that stated, "The patient's hospital course was also complicated by Clostridium difficile colitis, which she has also been treated for with Flagyl."

The clinical record review for Patient #8 (Patient #9's roommate for a time (see above)) was completed on 03/15/11. The clinical record review revealed a history and physical that stated while the 78-year-old patient was in rehabilitation following an ankle fracture suffered in 07/10, he/she developed an inability to eat, diarrhea, and general weakness. The history and physical stated he/she was transferred to a local hospital where he/she was diagnosed with C. difficile colitis and "severe malnutrition." The patient's past medical history did not have any indication of vancomycin-resistant enterococcus. The patient was then transferred to the facility for "further management."

The clinical record review revealed a physician's order dated 09/26/10 that stated to stop isolating the patient for C. difficile. The clinical record review did not clearly and definitively describe the patient as being free of the symptoms of C. difficile colitis.

The clinical record review revealed the patient was in room 44B on 10/01/10 until his/her discharge on 10/14/10. The clinical record review revealed a nursing flow sheet dated for the morning shift on 10/01/10 that stated the patient had diarrhea.

The clinical record review revealed a nursing flow sheet dated 10/02/10 at 8:50 A.M. that stated the patient had diarrhea.

The clinical record review revealed a nursing flow sheet dated 10/03/10 that indicated from 7:00 A.M. to 7:00 P.M. the patient had five stools.

The clinical record review revealed a nursing flow sheet dated 10/07/10 that stated between 7:00 A.M. and 7:00 P.M. the patient had extra large diarrhea.

The clinical record review revealed a physician order on 10/12/10 and on 10/14/10 that stated to collect a stool specimen for C. difficile.

The clinical record review revealed a final laboratory report dated 10/14/10 that stated the patient's culture was positive for C. difficile.

Review of the infection control policy III-3, "Determination of Isolation" was completed on 03/15/11. The review revealed, "Patients with a history of (multidrug resistant organisms) infection/sepsis/colonization will be placed into Enhanced Contact Precautions." The review revealed, "The charge nurse or Registered Nurse assigned to the patient may: send stools for C. diff ..." and "the nurse should note on the order sheet: 'Isolation Precautions_______per protocol for (reason)' and Stool sent for C. diff per protocol'".

Review of the facility's Appendix A (attributed to the Centers for Disease Control) stated patients are to remain in contact isolation for the duration of the illness.

On 03/15/11 at 11:45 A.M. in an interview, Staff B stated he/she did know of Patient #9's C. difficile infection, and concluded it was the result of the usage of antibiotics. He/she denied examining the roommate's (Patient #8) clinical record to determine whether, based on the laboratory results of 10/14/10 for Patient #8 and of 10/16/10 for Patient #9, the infection started there and spread to Patient #9. He/she stated although the patient was removed from isolation by the physician's order of 09/26/10 and by a 24-hour absence of symptoms, he/she expected the patient to be returned to isolation when symptoms returned.

On 03/15/11 at 3:00 P.M. in an interview with Staff B, Staff F and Staff E, they did not dispute the finding Patient #9 was free of C. difficile upon admission, but was cultured positive for it at about the same time as his/her roommate, Patient #8. They said they were unable to find a history of vancomycin-resistant enterococcus for Patient #8. They said they were unable to ascertain from the clinical record whether the Patient #8's symptoms of C. difficile had returned, but agreed the patient had had diarrhea (as indicated in the clinical record) after being removed from isolation.

Observation of wound care for patient #3 on 03/14/11 at 11:45 AM revealed staff member C washed his/her hands and then layered three pair of gloves prior to entering patient # 3's room. The nurse then proceeded to remove the soiled dressing from the gastrostomy tube site (an abdominal surgical site created for tube feedings). The nurse cleansed the wound, removed the soiled gloves, and applied a clean dressing to the site. The nurse then removed a soiled dressing from the patient's coccyx, cleansed the pressure sore, removed gloves, reached into his/her pocket to retrieve a camera, photographed the patient's coccyx and heels, removed gloves, and applied the new dressing. Employee C failed to wash his/her hands after removing soiled gloves, and instead continued to unlayer the gloves applied prior to entering the patient's room.

This substantiated complaint number #OH00059525.