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Based on policy and procedure review, open medical record review, direct observation, and staff interviews, hospital staff failed to ensure understanding of enteric isolation precaution status on a patient transferred to the Operating Room (OR) and failed to ensure proper room cleaning for 1 of 2 OR transfers observed. (Pt # 5)
The findings include:
Review of hospital policy titled "Transmission-Based Precautions", dated 05/2015, revealed "...Contact Precautions is a method designed to reduce the risk of transmission of micro-organisms by direct or indirect contact. Contact Precautions are used for patients with known or suspected infections....The Infection Preventionist or designee reviews isolation status for patients on a regular basis...Contact Precautions ....7. Patient transport....c. Patients may be transferred to other areas of the facility or other facilities for testing or therapy after the receiving department or facility has been informed of isolation status. ..."
Review of hospital policy titled "Management Guidelines of the Patient with Clostridium Difficile Infection" (CDI), dated 08/2014, revealed "...9. Transmission Based Precautions Confirmed CDI....b. Contact Precautions and any facility-specific measures should be initiated as directed....d. Equipment Sanitation i. Sodium hypochlorite (bleach) 1:10 solution (diluted) or other agent with sporicidal activity is the recommended agent for killing C. difficile spores in the environment and for equipment disinfection. ..."
Open medical record review for Pt # 5, on 06/15/2016, revealed the patient was admitted to Hospital A as a transfer from another acute care hospital. Review of the History and Physical (H&P), dictated 06/08/2016 at 2009, revealed the reason for admission was "...Ongoing management of decubitus ulcers and comprehensive medical care including rehabilitation. ..." H&P review revealed "...Clostridium difficile colitis....present on admission. ..." Review of Nursing Admission revealed "...Communicable diseases: Has a history of being in isolation on previous hospitalization for c-diff (CDI)...Multi-drug resistant organism....Clostridium difficile....Precaution/isolation....MDRO (Multi-drug resistant organism)/ contact precautions: Clostridium difficile, MDRO specimen type: stool, date cultured: date unknown. ..." Review of "OPERATIVE/PROCEDURE REPORT", dated 06/14/2016 revealed Pt # 5 was taken to the Operating Room (OR) and underwent procedures to aspirate a hematoma (draw off or remove clotted blood) and excise necrotic tissue from a wound (remove non-living tissue to help in healing).
Direct observation on 06/14/2016 revealed Manager # 1 and RN # 1 transported Pt # 5 to the OR for a procedure. Observation revealed an enteric (CDI) isolation precautions sign on the door of the patient's room. Observation revealed RN # 2, the patient's nurse, was in the room and reported to Manager # 1 that Pt # 5 had a history of CDI. Observation revealed the patient was moved to an OR stretcher and transported to the OR. Once in the OR, observation revealed a yellow strip with the word "Contact" on a communication board. Interview with Manager # 1 at that time revealed Pt # 5 was on regular contact precautions, not enteric precautions. Interview revealed Pt # 5 had a "history of (CDI)".
Interview with Administrative Staff (AS) # 1, on 06/15/2016 at 0945, revealed the hospital's policy/practice was to place a patient on isolation whenever the patient arrived directly from another hospital with a history of CDI and isolation at that hospital. Interview revealed Pt # 5 was, and should be, on enteric isolation precautions.
Interview with Manager # 1, on 06/16/2016 at 1430, revealed the OR process is for Manager # 1 to review the patient's chart / kardex for isolation precautions the day before surgery. Interview revealed this was done on Pt # 5 and Manager # 1 saw the MDRO precautions, but did not see the CDI precautions. Interview revealed Manager # 1 also asks for a handoff report when picking the patient up for transport to the OR. Interview revealed "I did not know" Pt # 5 was on CDI precautions. Interview revealed in handoff report the nurse said Pt # 5 had a "history of" which Manager # 1 thought would indicate they were "clear now". Further interview revealed "it's a process problem".
Interview on 06/16/2016 at 1515 with three (3) OR staff members (RN # 5, Surgical Tech [ST] # 3, and ST # 4) revealed the staff cleans the OR room after each procedure as well as at the end of the day. Interview revealed scheduled patients are looked up the day before to check for isolation status and the staff have "huddles" in the morning to go over the cases for the day. Interview revealed they clean after patients on standard precautions and regular MDRO precautions with "purple top" wipes. After C difficile (CDI) patients, rooms are cleaned with "bleach (wipes), orange tops". Interview revealed ST # 4 cleaned the room after Pt # 5's case. Interview revealed "I did not realize it was c diff...cleaned with purple top (wipes)." Interview revealed ST # 4 did not clean with bleach / orange top wipes and revealed policy was not followed.
NC00116583