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Based on interview, record review, and document review, the facility failed to ensure an effective governing body was legally responsible for the conduct of the hospital. The governing body failed to ensure the hospital developed and maintained an effective and comprehensive program for infection control specifically related to training, knowledge, monitoring, surveillance and enforcement of policy and procedures pertinent to facility practices.

Refer to the following Tags:

A-0749-Failure to promote an active program for the prevention, control, monitoring, surveillance and investigation of infections and communicable diseases.

A-0756-Failure to address systematic breakdown of infection control issues.

The cumulative effect of these systematic practices TAGs A-0749 and A-0756 resulted in the failure of the facility to deliver statutory mandated care to patients.

The facility failed to ensure the hospital protected patients from infection control issues by:

-Failure to implement a comprehensive system-wide infection control program (TAG A-0749).

-Failure to provide a system to safely identify, supervise, evaluate, and monitor the care of patients on isolation (TAG A-0756).

The cumulative effect of these deficient practices at TAGs A-0749 and A-0756 resulted in the failure of the facility to ensure patients were protected from infections and communicable diseases.

Based on interview, record review and policy review, the facility failed to ensure written notice was sent to two patients (Patient #10 and Patient #30) finalizing the investigation of the grievance process in a timely manner.

Findings include:

Patient #10

Patient #10 was admitted on 2/29/12 with diagnoses including chronic kidney disease stage III, hydronephrosis, Alzheimer's disease, dysphasia, neurogenic bladder and failure to thrive.

On 4/18/12 in the afternoon, the facility Complaint Log was reviewed. The documentation in the log revealed on 3/7/12 a family member of Patient #10 lodged a complaint concerning the quality of care the patient received.

The Complaint Log indicated an investigation was started on 3/7/12 and an initial letter to the family member was sent on 3/8/12. The log indicated the action taken included staff interviews and a chart audit. The resolution indicated staff remediation with house training.

On 4/18/12 in the morning, the Director of Quality/Risk Management (DQM) produced a letter to Patient #10's family member dated 4/17/12, that indicated the finalization of the investigation. The DQM indicated the letter had not been mailed to Patient #10's family member.

On 4/20/12 in the afternoon, the Social Worker at the skilled facility (where Patient #10 was transferred on 3/26/12) was interviewed by telephone. The Social Worker revealed the family member of Patient #10 indicated she had complained to the nurses at the facility concerning the quality of care Patient #10 received. The Social Worker indicated the family member received one letter from the facility and was never advised of the conclusion of the investigation at the facility. The Social Worker indicated the family member was still upset concerning the care Patient #10 received at the facility. The Social Worker advised the family member to pursue the complaint with the Ombudsman and the Health Division.

Policy # 1.320 entitled, "PATIENT COMPLAINT/GRIEVANCE POLICY" (revised 5/10) documented the following:

"...For the purpose of this policy the terms "patient complaints" and "grievances" are synonymous and the two terms may be used interchangeably throughout this policy.

Most complaints should be resolved within seven days, but for more complex issues, the maximum time frame for written communication must not exceed thirty days from date of the receipt of the complaint/grievance..."

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Patient #30

Patient #30 was admitted to the facility on 1/30/12 and discharged on 2/6/12 with diagnoses including disuse myopathy, functional debilitation, aspiration pneumonia, history of seizures, status post cerebrovascular accident, chronic mastoiditis, benign prostatic hypertrophy and hypertension.

The daily progress/narrative note on 2/4/12 at 2:00 AM, documented the registered nurse in charge was notified by staff the patient had called 911.

The Quality/Risk Director stated he did not review the patient's medical record when investigating the complaint.

There was no documented evidence a letter was sent to the patient documenting the results of the investigation.

Patient Complaint/Grievance Policy 1.320, revised 5/10, documented:

" ...CUSTOMER COMPLAINTS/GRIEVANCES-DOCUMENTATION REQUIREMENTS...6. A final written communication must be sent to the patient/family/or legal representative, even if other methods of communication are used (such as a family meeting) ... "

Based on interview, record and policy review, the facility failed to conduct a proper assessment and meet the needs for one patient (Patient #10), and failed to ensure registered nurses properly supervised the nursing care for two patients (Patient #1 and Patient #24).

Findings include:

Patient #10

Patient #10 was admitted on 2/29/12 with diagnoses including gastric outlet obstruction, uncontrolled atrial fibrillation, left atrophic kidney and mild hydronephrosis, dementia and need for rehabilitation therapy.

The History and Physical for Patient #10 dated 2/29/12 on admission to the facility revealed the patient had a white blood count (WBC) of 7000 (normal 4300-10800). The patient's temperature was 97.5 Fahrenheit (F).

Patient #10 had a PICC (Peripherally Inserted Central Catheter) line and was receiving TPN (Total Parenteral Nutrition) at the facility for poor appetite and refusing food.

The documentation in Patient#10's clinical record was unclear as to when and where the PICC line was inserted.

There was no documentation in the Interdisciplinary Plan of Care that addressed Patient #10's PICC line monitoring for signs and symptoms of infection.

The facility's Daily Progress/Narrative (nurses notes) for Patient #10 documented the following: "...Mar 05 2012 0500 (5:00 AM) Hourly rounds made to (unable to read) safety and comfort TPN @ (at) 62cc (cubic centimeter)/hr. (hour) infusing well. Needs attended call light in reach.
-2020 (8:20 PM) Daughter in to see the father. States her father did not eat his dinner & (and) concerns of her father's change in level of consciousness (sic). Check the temperature-100.9 orally. Tylenol given PRN (when necessary). Charge nurse called (Patient #10's physician's name) and ordered transfer to (acute care hospital name) ER (emergency room) r/o (rule out sepsis)..."

Patient #10 was transferred to the acute care hospital on 3/5/12 by ambulance.

On 4/20/12 in the afternoon, the Social Worker at the skilled nursing facility where Patient #10 was transferred indicated the family member of Patient #10 was upset because the facility did not call for an ambulance until the family member brought it to the attention of the staff. The Social Worker indicated the family member stated by then the patient had a high fever and was almost non-responsive.

Policy 3.655 (revised 08/08) Early Recognition and Response to Changes in Patient Condition documented:

"...Upon signs of clinical deterioration as defined by the MEC (medical executive committee), resources will be mobilized to provide appropriate care and treatment. Signs of clinical deterioration that will trigger response activation and a call to the patient's physician may include, but not limited to: temperature more than 101.5. Conscious state any deterioration..."

The Emergency Room Admission Notes dated 3/5/12, documented Patient #10 was diagnosed with fever, leukocytosis (high white count) and altered mental status.

The laboratory findings on Patient #10 dated 3/5/12, documented the patient's WBC was 18.5 with a temperature of 102.8 F. Patient #10's blood culture dated 3/5/12 and results 3/7/12 indicated the patient had bacteremia (blood infection) with Gram-positive cocci.

The acute care facility's Discharge Summary dated 3/26/12 documented Patient #10 required 10 days of intravenous therapy with Zosyn (antibiotic) and a PICC (Peripherally Inserted Central Catheter) change due to the bacteremia that was found on Patient #10 at admission to the acute care hospital on 3/5/12.

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Patient #1

On 4/5/12, Patient #1 was admitted with a diagnosis of cerebrovascular accident.

Patient #1's interdisciplinary daily documentation showed contact isolation for MRSA (Methicillin Resistant Staphylococcus Aureus) of the nares from 4/7/12 through 4/20/12. A sign posted outside Patient #1's door indicated contact isolation at 1:30 PM on 4/20/12.

Patient #1's medical record lacked a physician's order for contact isolation, treatment, and laboratory testing for MRSA of the nares.

On 4/20/12 at 1:30 PM, seven people were observed in Patient #1's room, including a staff member and several visitors. They interacted with and assisted Patient #1 to a wheelchair and wheeled Patient #1 down a hallway. Two visitors were observed going in and out of the room several times. During this process, none of the seven people present wore gloves.

According to the facility's policy Isolation Precautions (last revised 1/01), under "...Contact Precautions 1. Gloves and Hand Washing--Wear gloves when entering room..."

On 4/20/12 at 1:45 PM, Employee #22, the charge nurse, was informed of the event involving Patient #1, the staff member, and visitors. Employee #22 was asked to review the medical record and clarify whether or not Patient #1 should be on isolation and/or receive treatment and testing.

As of 4/20/12 at 4:25 PM, Employee #22 failed to clarify the requested information.



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Patient #24

Patient #24 was admitted to the facility on 4/10/12 with diagnoses including chronic obstructive pulmonary disease, respiratory failure, debility, status post ventilator, hypothyroidism and history of panic disorder.

The infectious disease physician examined the patient on 4/13/12. The consultation note documented an assessment of history of questionable bacteremia, pneumonia and funguria. The infectious disease physician recommended the facility obtain the blood culture from the transferring facility and to obtain a sputum gram stain and culture.

The laboratory results documented the sputum specimen collected on 4/15/12 showed moderate growth of coagulase positive staphylococcus in the sputum on 4/17/12.

On 4/18/12 at 2:10 PM, Patient #24 was observed sitting outside of the facility in a wheelchair. The patient was observed taking the mask off to drink and talk with the surveyor.

On 4/18/12 at 9:00 AM, contact isolation poster was observed outside the door of room 135. Charge Registered Nurse #1 (RN) stated the patient was on droplet precautions. The Charge RN #1 was unable to explain why the contact isolation poster and not the droplet precautions poster was outside the patient's room.

On 4/19/12 at 8:30 AM, RN #1 explained a physician order was required to place a patient in isolation. The type of isolation depended on the infectious disease physician's order.

RN #1 acknowledged there was no physician order to place the patient in isolation for the patient in room 135.

On 4/20/12 at 10:10 AM, RN #1 explained Patient #24 was placed in preventative isolation. The RN stated she was not sure why the patient was initially placed in contact isolation. The RN acknowledged there was no physician order for the patient to be in any type of isolation.

On 4/20/12 at 10:30 AM, RN #1 explained the infectious disease physician was contacted regarding the lack of isolation order for the patient in room 135. The RN relayed the infectious disease physician acknowledged he did not write an order for isolation because he did not feel the patient needed to be in isolation.

On 4/19/12 at 10:50 AM, the administrator acknowledged the physicians rarely took a pro-active role to discontinue isolation. The administrator indicated the medical director of the facility was notified of the physicians taking a more pro-active role with isolation.

The administrator stated the RN should receive an order from the physician upon admission to the facility to place in isolation.

Based on observation, interview and record review, a patient's medical record did not contain information to justify interventions observed and documented for 2 of 30 patients (Patient #1 and Patient #24).

Findings include:

Patient #1

On 4/5/12, Patient #1 was admitted with a diagnosis of cerebrovascular accident.

Patient #1's interdisciplinary daily documentation showed contact isolation for MRSA (Methicillin Resistant Staphylococcus Aureus) of the nares from 4/7/12 through 4/20/12. A sign posted outside Patient #1's door indicated contact isolation at 1:30 PM on 4/20/12.

Patient #1's medical record lacked a physician's order for contact isolation, treatment, and laboratory testing for MRSA of the nares.

On 4/20/12 at 1:45 PM, Employee #22, the charge nurse, was unable to provide documented evidence why the patient was on isolation, if the patient received treatment, and orders for testing.



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Patient #24

On 4/19/12 at 8:30 AM, RN #1 explained a physician order was required to place a patient in isolation. The type of isolation depended on the infectious disease physician's order.

RN #1 acknowledged there was no physician order written for the patient in room 135.

On 4/19/12 at 10:50 AM, the administrator stated the RN should receive an order from the physician upon admission to the facility to place patients in isolation.

Based on observation, interviews, record review and policy review, the facility failed to ensure patients were monitored, accessed and educated on the use of personal protective equipment (PPE) for isolation (Patient #2), failed to ensure visitors were monitored and educated on the use of PPE for patients on isolation (Patient #8 and Patient #19), and failed to ensure staff was educated and monitored in following policies and procedures pertaining to the facility infection control program (Patient #19 and Patient #20).

Findings include:

1.) Patient #2

Patient #2 was admitted to the facility on 4/5/12 with diagnoses including diabetes, weakness, hypertension, MRSA (Methicillin Resistant Staphylococcus Aureus) of the nares and renal insufficiency.

On 4/18/12 at 8:30 AM, Patient #2 was observed self propelling around the hallway in his wheelchair. The patient did not wear PPE and wore the mask under his chin.

A Licensed Nurse (LN) indicated Patient #2 was on droplet isolation for MRSA and the mask should have covered his nose and mouth.

The door sign on Patient #2's room indicated the patient was on contact isolation precautions. The sign on the door documented gown and gloves should be worn when entering the room.

On 4/19/12, the contact isolation sign on Patient #2's door was observed to have "mask" added in marker on the sign.

Patient #2 was observed on 4/18/12 at 12:50 PM, propelling in the wheelchair into the facility cafeteria. The patient did not wear PPE and wore the mask under his chin.

On 4/18/12 at 12:52 PM, the Chief Nursing Officer (CNO) indicated Patient #2 should not have been in the cafeteria. The CNO indicated Patient #2 was non-compliant and was told many times he needed to wear a mask when he left his room.

On 4/18/12 in the afternoon, Patient #2 was observed in physical therapy co-mingling with other patients. Patient #2 did not wear PPE or a mask.

Patient #2 was observed at various times during the survey on 4/18/12 and 4/19/12, self propelling his wheelchair in the hallway of the facility without PPE or a mask.

Patient #2's laboratory report dated 4/10/12, revealed a culture positive for MRSA of the nares.

On 4/18/12 at 2:25 PM, Patient #2 was observed in the therapy gym working with Employee #18 without wearing an isolation mask.

On 4/18/12 at 2:30 PM, Patient #2 was observed in the therapy gym working with Employee #19 wearing an isolation mask.

On 4/18/12 at 3:10 PM, Patient #2 was observed self-propelling a wheelchair in a hallway without wearing an isolation mask.

On 4/18/12 at 3:55 PM, Patient #2 was observed self-propelling a wheelchair near a nursing station without wearing an isolation mask.

On 4/18/12 at 4:00 PM, Patient #2 was observed interacting with Employee #20 at a nursing station without wearing an isolation mask. A nurse was asked if Patient #2 was supposed to wear an isolation mask. The nurse did not answer.

2.) Patient #8

Patient #8 was admitted on 4/14/12 with diagnoses including right total arthroplasty, anemia, polyneuropathy of the left shoulder and both knees, hypertension, coronary disease, MRSA of the nares and VRE (Vancomycin Resistant Enterococcus) of the rectum.

On 4/18/12 in the afternoon, a family member of Patient #8 was observed sitting on the patient's bed. The family member wore no PPE or a mask as indicated on the sign on the door. The family member was observed leaving the room without using hand sanitizer or soap and water.

On 4/18/12 in the afternoon, a Licensed Nurse indicated Patient #8's family member was informed PPE and a mask should be worn when visiting the patient.

A Respiratory Therapist (RT) observed the family member of Patient #8 and indicated the family member should have worn a mask, gloves and a gown. The RT indicated the family member should not have sat on the bed.

On 4/18/12 in the afternoon, Patient #8's sign on his room door indicated he was on contact isolation (gown and gloves).

On 4/18/12 in the afternoon, the Charge Nurse indicated Patient #8 was on contact and droplet isolation for MRSA of the nares and VRE of the rectum.

The Admission Screening Form for Patient #8 dated 4/15/12, documented the patient was on contact isolation. The documentation revealed the patient was positive for VRE and MRSA. The sites of the infections were not documented on the screening form.

The following guidelines and policies were reviewed on 4/18/12 through 4/20/12:

The facility Visitation Rights and Guidelines revealed, "Visitors are discouraged from sitting on the patient's bed. If additional seating is needed, please ask a staff member to find additional chairs for the room."

Policy [Infection Control] 50-TRAFFIC CONTROL (revised 7/09) documented, "...B. Visitors are requested to speak with a nurse before entering a room of a patient on isolation precautions and, if indicated, be instructed in the appropriate use of gown, mask, gloves or additional precautions. C. Visiting polices (sic) are monitored by the nursing staff for patient care areas in compliance with the established hospital visiting hours. Department directors are responsible for monitoring patient visitation in their respective departments..."

Policy 19.175-SURVEILLANCE PROGRAM (revised 1/08) documented, "...3) Management of patients with VRE: a) Patients will always be placed in CONTACT isolation, no matter what the source of the VRE is or whether the patient is colonized or infected. Contact isolation for VRE patients means: i) Gloves and gowns when coming into contact with the patient or the patient's environment (their bed area). ii) Masks are NOT required. iii) Remove gloves and gown when leaving the room. Clean hands with waterless hand gel or soap and water..."
"...8) Dining room Access: a) Isolation patients who go into the dining room wear appropriate PPE and the table is adequate disinfected after use..."
"...13) Therapy: iii) Patients going to therapy outside of the room are to wear the appropriate PPE and do adequate hygiene before and after therapy. Encourage the use of waterless alcohol gel during therapy and when in room. iv) Patient has to wear mask, gloves or gown (mask if droplet precautions), gown if patient's clothes are soiled..."

3.) On 4/18/12 at 10:40 AM and 2:30 PM, the Medication Nurse (Employee #17) was observed pushing the medication cart into an isolation room and then into a non-isolation room.

On 4/18/12 in the afternoon, Employee #17 indicated she did not clean the cart when she left an isolation room. Employee #17 indicated it was alright to go into the room with a patient who was on isolation as long as the cart was not pushed all the way into the room.

On 4/19/12 in the afternoon, Registered Nurse #5 indicated she did not take the medication cart into the patient rooms. Registered Nurse #5 indicated patients had a cabinet with their own medications. The medication cart held syringes and other equipment. Registered Nurse #5 indicated she left the cart outside, took out what she needed and left the cart in the hallway.

On 4/20/12 in the morning, the Chief Executive Officer indicated the carts were taken into the rooms due to the fire code and not having clutter in the hallways.

The facility had no policy pertaining specifically to bringing the medication carts into isolation rooms.

Taken from the website of Centers for Disease Control and Joint Commission recommendations:

"...Standard EC.1.10, EP 4 requires that healthcare organizations conduct a risk assessment to determine the potential adverse impact of equipment, supplies and other factors on the safety and health of patients, staff, and others. EC.1.20, EP 5 requires that healthcare
organizations use the information from the risk assessment to implement procedures and controls to address the potential adverse impact. Infection control issues need to be assessed. What do you do for the patient in isolation? If you take the medication
cart/emergency medication box into an isolation room how will it be decontaminated before it is taken into another patient room. What general cleaning procedures are in place for medication carts/emergency medication boxes? Your organization's policies and procedures
should reflect information obtained from the risk assessments conducted for your facility...."




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4.) On 4/19/12 at 2:00 PM, a Respiratory Therapist (RT) indicated there were some serious concerns about infection control practices within the facility. The RT had witnessed several patients who were designated on isolation precautions allowed to roam freely throughout the facility outfitted without gowns, gloves or masks. The RT observed the patients entering the employee/visitor dining room area, and felt this was neither a safe nor a correct practice.
The RT witnessed on several occasions the floor nurses removing the water pitchers from the rooms of patients on isolation precautions and taking them directly into the patient/visitor dining room area and refilling them at the same ice and water stations used by employees and visitors.




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5.) On 4/20/12 at 12:55 PM, the chief nursing officer (CNO) acknowledged all patient names identified on the infection control surveillance log were patients who developed hospital acquired infections.

On 4/20/12 at 1:05 PM, the RN night supervisor explained when the print out from the laboratory was received, patient charts would be reviewed to see if the organism causing the infection was acquired at the facility or from the transferring facility. The RN night supervisor acknowledged there had been some delay in receiving culture results from the laboratory.

The RN night supervisor explained once the facility received the culture result, the physician would be notified to order a type of isolation.

6.) On 4/19/12 at 10:30 AM, Physical Therapist (PT) #1 was observed assisting Patient #6 with walking. The patient was wearing a yellow isolation gown. The PT was observed working with the patient and did not wear gloves. The patient was identified with a diagnosis of clostridium difficile.

The PT was observed washing his hands with soap and water, went back to Patient #6, touched the patient, and then put gloves on to assist Patient #23.

7.) On 4/19/12 at 11:35 AM, a Certified Nursing Assistant (CNA) was observed entering Room 130W with the patient's lunch tray. The lunch tray was identified for the patient in Room 128W. The patient in Room 130W opened the lid of the hot food. The CNA was informed the wrong lunch tray was delivered to the patient. The CNA removed the lunch tray from Room 130W, placed the lunch tray back on the food cart and provided the patient with the correct lunch tray. Another CNA went to remove the returned lunch tray to deliver to the patient in Room 128W. The Nutrition Services Manager stopped the second CNA from delivering the lunch tray to Room 128W.

The Nutrition Services Manager explained the tray removed from Room 130W should have been discarded and a new tray ordered from the kitchen for the patient in Room 128W.

8.) On 4/18/12 at 1:45 PM, Charge RN #1 explained when a patient was in respiratory isolation, the patient should not come out of the isolation room. If the patient was in contact isolation, the patient could leave the isolation room to go outside to smoke if the patient wore a gown. If the patient was identified with Clostridium difficile (C-diff), the patient would be required to wear a gown, but would not be required to wear gloves.

On 4/18/12 at 1:50 PM, RN #1 explained when a patient was in contact isolation, the patient was required to wear a gown and gloves to leave the isolation room to go outside to smoke.

On 4/19/12 at 10:40 AM, the Regional CNO explained if a patient had an active case of C-diff, the rehabilitative therapy would be administered in the patient's room. If there were no active symptoms, the patient could go to the gymnasium with a gown on when leaving the isolation room. The Regional CNO acknowledged the facility policy did not identify how many days the patient needed to be symptom free before the patient could leave the isolation room and receive rehabilitative therapy in the gymnasium.

On 4/20/12 at 9:35 AM, physical therapy assistant #1 explained when a patient was in droplet isolation, the patient was required to wear a mask in the gymnasium. If the patient was diagnosed with C-diff, most of the time, the patient would receive rehabilitative therapy in the patient's room.

On 4/20/12 at 9:40 AM, Physical Therapist #3 explained if a patient had MRSA in the nares, the patient was required to wear a gown and mask. If a patient had C-diff and was continent, the patient would be required to wear a gown and gloves in the gymnasium. The therapy staff would be required to wear gloves when working with the patient and wash hands with soap and water.

On 4/20/12 at 10:00 AM, Physician #1 explained if a patient was in respiratory isolation, the patient would be permitted to go to the gymnasium if the patient wore a mask. If the patient had C-diff, and had good control of the bowels, the patient could go to the gymnasium. Physician #1 expressed it would be best to provide rehabilitative therapy in the patient's room when the patient was diagnosed with C-diff.

Physician #1 explained a patient could be considered for removal from isolation after the antibiotic therapy for C-diff was completed (10 days) and the patient had three days of no loose stools.

On 4/20/12 at 10:30 AM, Physician #2 explained when a patient was in respiratory isolation, the patient was required to wear a mask to receive treatment in the gymnasium. Physician #2 stated when a patient was diagnosed with C-diff, the patient should remain in the isolation room to receive therapy. The physician explained once the treatment for C-diff was completed and the patient was removed from isolation, the patient would be permitted to go to the gymnasium for therapy.

Physician #2 acknowledged the physician expected the RN to contact the infectious disease physician on the day of admission to receive an order for any type of isolation required for the patient.

9.) On 4/20/12 at 1:20 PM, the Regional CNO acknowledged the facility did not have an active infection control program. The Regional CNO stated environmental rounds were completed quarterly.

On 4/20/12 at 1:30 PM, the CNO stated there had been no infection control meeting since October 2011.

Surveillance Program Policy 19.175, (revised 1/08) documented:

"...PURPOSE:...2. To establish appropriate patient placement for isolation or other special precautions as indicated..."

"...4. To monitor compliance with appropriate infection control standards in the delivery of patient care..."

"Daily Rounds...2. By making rounds to all inpatient care areas and outpatient areas daily, or as often as possible, the Infection Control Preventionist will receive useful information on infections cases, suspected cases and potential problem areas in the hospital's environment..."

Management of Patient with Multi-Drug Resistant Organisms (MDRO) Policy 10/265, (revised 6/10) documented:

"...13) Therapy:...Therapy is responsible for cleaning/disinfecting all equipment used by the isolation patient prior to use on another patient..."

"a)...iv) Patient has to wear mask, gloves, or gown (mask if on droplet precautions, gown if patient's clothes are soiled)..."

"a)...vi) Therapy MUST be notified in advance of isolation status (1) Ideally, therapy will schedule patient for the last appointment of the day to allow time to clean between patients..."

Management of Patient with C-Difficile Policy 19.270 (revised 6/10) documented:

"PROCEDURE: ...B. Out of the Room 1. Ensure that precautions are maintained to minimize the risk of transmission of microorganisms to other patients and contamination of environmental surfaces or equipment..."

"SPECIAL PRECAUTIONS:...b. Patients with diarrhea and incontinence contained 1. May go to the gym for therapy a. Wear gown and gloves b. Staff wear gown and gloves c. Equipment will be disinfected after each use..."

Complaint #NV00031102


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10.) Patient #19

On 4/14/12, Patient #19 was admitted with diagnoses of VRE (Vancomycin Resistant Enterococcus) in the urine, debility/rehabilitation, coronary artery disease, and atrial fibrillation.

On 4/17/12, a physician ordered contact isolation for VRE in the urine.

According to the facility's policy Isolation Precautions (last revised 1/01), under "...Contact Precautions 1. Gloves and Hand Washing--Wear gloves when entering room..."

On 4/19/12 at 3:55 PM and at 4:00 PM respectively, a physical therapist and a certified nursing assistant were observed entering and exiting Patient #19's room without wearing gloves.

On 4/20/12 at 1:30 PM, a staff member approached Patient #19 regarding a lunch tray inside the room without wearing gloves. The staff member interacted with Patient #19, saw the surveyor watching, and then obtained an isolation gown and gloves.

11.) Patient #20

On 4/17/12, Patient #20 was admitted with diagnoses of end stage renal disease, anemia of chronic kidney disease, hypertension, renal osteodystrophy, status post coronary artery bypass graft and aortic valve replacement, hospital acquired pneumonia resolved, and resolved ventilator-dependent respiratory failure.

On 4/17/12, a physician ordered contact isolation for clostridium difficile.

On 4/19/12 at 9:45 AM, a visitor identified as Patient #20's son was present in the room and was observed having direct contact with Patient #20. The visitor was not wearing personal protective equipment, such as a gown and gloves.

On 4/19/12 at 9:50 AM, a physician was interviewed regarding the visitor in Patient #20's room. The physician was asked why the visitor was not wearing a gown and gloves.

The physician answered, "that is a good question. You probably catch things like this all the time."

The physician then ordered stools for clostridium difficile.

According to the facility's policy The Management Of Patient With C-Difficile (last revised 6/10), under procedure A. Patient Room..."3. Protect that part of yourself that may come in contact with the patient or patient's environment. a. Always remove gloves and gown before leaving the patient's room and wash hands immediately with soap and water..."

The facility staff did not follow or were unaware of their policies on infection control. The Chief Nursing Officer was the acting infection control nurse for the facility and was not able to monitor and educate staff on the proper use of PPE and surveillance of infections throughout the facility. The staff did not monitor patients and their visitors on the proper use of PPE. The signs on the patients' doors were conflicting with what type of PPE should be worn. The facility lacked a comprehensive infection control program.

Based on interview, the facility failed to ensure the Quality Assessment and Performance Improvement Program included a comprehensive ongoing program that showed measurable improvement in indicators for which there was evidence that would improve health outcomes for Infection Control.

Findings include:

On 4/20/12 in the afternoon, the Director of Quality/Risk Management (DQM) revealed he had no evidence of documentation for Performance Improvement, tracking and trending, or surveillance of infection control. Upon questioning specifically whether the facility had a system in place for monitoring of infection control for patients who had infectious disease and were on isolation, the Director of Quality/Risk Management (DQM) responded negatively, and revealed he had not received any data for the quarter. The DQM indicated he was employed at the facility as the DQM for a couple of months and was in the process of collecting the needed data from all departments.

Based on observation, interviews, records and policy review, the facility failed to ensure hospital leadership was responsible for a comprehensive hospital-wide Quality Assurance program and training programs that addressed issues concerning infection control and were responsible for the successful corrective action plans in the problematic areas.

Findings include:

On 4/19/12 at 5:00 PM, the Medical Director indicated he was aware there were issues with isolation procedures at the facility. The physician indicated there were too many patients transferred from the acute care hospitals with infectious disease.

The Medical Director indicated he had requested a consultation with an infectious disease physician in order to assist the facility with organizing a protocol on infection control measures.

The Medical Director indicated the Chief Nursing Officer was organizing an isolation protocol. The Medical Director indicated there was a lack of awareness on isolation procedures and that everyone needed to be made aware including staff, visitors and some physicians.

The Medical Director indicated the physicians need to do repeat cultures on patients who were admitted with an infection from the acute care hospitals. The physicians need to determine by these cultures if it is safe to remove patients from isolation or not. The Medical Director indicated the facility would be making policies based on the infectious disease physician's recommendations.



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On 4/20/12 at 1:20 PM, the Regional CNO acknowledged the facility did not have an active infection control program. The Regional CNO stated environmental rounds were completed quarterly.

On 4/20/12 at 1:30 PM, the CNO/Acting Infection Control Officer stated there had been no infection control meeting since October 2011.