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Based on record review and interview, the facility failed to develop amd implment a policy and procedure to ensure the performance of oral hygiene.

Failure to ensure the performance of oral hygiene created risk for harm from poor oral and dental health, especially related to infection.

Findings included:

1. a. Record review of the plan of care between 02/10/18 and 06/27/19 for Patient #1 indicated that there was one plan of care to provide oral care every shift, as of 11/20/18. That order was written to stop after 45 days and a note indicated that it was renewable. There were no other entries indicating oral care was part of the patient's plan of care over that period.

b. Record review of the medical record between 07/24/18 to 06/24/19 for one day each month showed that on 4 of 12 dates, oral hygiene was not recorded as being performed. On 4 of 12 dates, the record showed the patient completed oral hygiene but just once a day rather than every shift, as ordered. On another 2 of 12 dates, the record showed that the patient refused oral hygiene once during the day.

2. a. On 07/10/19 from 3:30 PM to 4:00 PM, the investigator interviewed Patient #1. The patient stated that between 02/04/18 and 06/27/19, staff did not offer her a toothbrush and toothpaste to perform oral hygiene. At times, she requested those items of the staff.

b. On 07/11/19 at 10:30 AM, the investigator interviewed the Director of Nursing and Clinical Services (Staff #2), who acknowledged the record review finding. At that time, she also stated that there was not a policy and procedure directing staff to ensure that patients regularly received oral hygiene while hospitalized.
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Based on record review and interview, the facility infection preventionist failed to manage the activities of the infection control program to ensure established specific goals to decrease different types of drug-resistant organism infections.

Failure to establish specific goals to decrease different types of drug-resistant infections created risk for harm to patients related to excess infection with pathogenic organisms, including those that are clinically difficult to treat.

Findings included:

1.a. Record review of the Annual Infection Prevention and Control Program for year end 2018 (including the plan for 2019) showed that there was "No Goal" established for the rate of multidrug-resistant organism (MDRO) infections for 2018. The report showed that in the column labelled rates, it did not contain calculated rates for the Northgate and First Hill sites. The report showed that the total number of infections (not the same as rates) decreased and the goal was labelled as "met" for 4 of 5 types of infections.

b. The same report showed that goals for CRE (carbapenem-resistant enterobacteriaceae, an intestinal pathogen) infection rates were not established for 2018 but the hospital reported a total number (not the same as rates) in the rates column as reduced. The section about whether the goal was met was recorded as met for the Northgate campus and not met for the First Hill campus.

c. The same report showed that goals for clostridium difficile (C-Diff, an intestinal pathogen) infection rates were not established for 2018. The hospital reported a total number of infections (not the same as rates) in the rates column as reduced. The section about whether the goal was met was left blank. Additionally, a specific goal was established for 2019 but data could not be located for the first quarter of 2019, as of July 2019.

2. On 07/10/19 at 1:00 PM, the investigator interviewed the Corporate Infection Preventionist (Staff #1). When rates and goals were discussed, she stated that all hospitals should establish specific goals for infection reduction for MDROs, CRE and C-Diff. When asked what occurs when a facility submits a report to her, as the Corporate Infection Preventionist, and the information is incomplete or mislabeled. She stated that she served as a consultant to the hospital infection preventionists and it was their responsibility to contact her for assistance and to manage activities of their own work for accuracy and completeness. Additionally, she stated that the 2019 corporate strategic plan did not address MDROs.
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