HospitalInspections.org

Based on interview and document review, it was determined that the hospital failed to ensure policies were developed and implemented to deal with a communicable disease outbreak, failed to assign infection control duties to a qualified individual for 2 instances of a scabies outbreak (Refer to A 748) and failed to provide evidence that all staff and patients were identified and treated for scabies according to CDC Guidelines, the standard for use as identified by the chief nursing officer for one (1) behavioral health unit (Refer to A 749). The cumulative effect of these systemic problems resulted in the hospital's inability to ensure a sanitary environment to avoid sources and transmission of infections and communicable diseases.

Based on document review and staff interview, the facility failed to ensure physician orders were followed for 5 (patients #23, 25, 27, 28, and 30) of 5 patients with orders for scabies on the behavioral health unit (BHU).

Findings include:

1. Patients #23, 25, 27, 28, and 30 medical records contained orders written on 3/28/14 for Permethrin cream (scabies treatment). The records lacked documentation that the order was completed.

2. Staff member #8 (RN House Supervisor and informatics staff) verified in interview beginning at 4:45 p.m. on 4/14/14 that the medical records lacked evidence that the orders were followed as indicated above.

Based on interview, the infection control officer failed to ensure policies were developed and implemented to deal with a communicable disease outbreak and failed to assign his/her duties to a qualified individual to act on their behalf for 2 instances of a scabies outbreak.

Findings include:

1. Staff member #1 (CNO) indicated the following in interview beginning at 10:30 a.m. on 4/14/14:
(A) The facility had "2 bouts" of scabies. He/she first indicated that it started staff member #14 and indicated that patients and employees were not treated with the episode in January and that there were no patients with scabies in January. Indicated he/she made the decision (not based on any policy or literature) to have patients visually checked for rashes in January 2014 and treated if needed.
(B) He/she did not maintain documentation of patients or staff checked and/or treated for scabies.
(C) The second episode occurred in March 2014 and involved patients and staff. All patients and staff were treated for scabies. The facility lacked proof of documentation that staff and patients were treated for scabies. He/she indicated that some employees went to their own physicians and did not turn in the paperwork.
(D) The facility has no policy for treatment of scabies and he/she followed CDC guidelines for treatment in March 2014.
(E) He/she has been in management, not infection control.

2. Staff member #3 (Infection Control Officer) indicated the following in interview beginning at 10:30 a.m. on 4/14/14:
(A) He/she did not deal with the scabies issue due to responding to JCAHO and ISDH requests. The issue was handled by staff member #1 (CNO).

Based on interview and document review, the facility failed to provide evidence that all staff and patients were identified and treated for scabies according to CDC Guidelines, the standard for use as identified by the chief nursing officer for 1 behavioral health unit (BHU).

Findings include:

1. Staff member #1 (Chief Nursing Officer- CNO) indicated the following in interviews beginning at 10:30 a.m. on 4/14/14:
(A) The facility has no policy for the treatment/control of scabies.
(B) He/she handled the scabies issue and not the Infection Control Officer.
(C) He/she made the decision in January to have patients checked for a rash when an employee on BHU was diagnosed with scabies. The decision was not based on any literature or policy. There was no documents maintained of the checks.
(D) The BHU had an issue with scabies again in March with both patients and staff and he/she used CDC guidelines to treat staff and patients.
(E) All patients on BHU and all staff were treated for scabies in March. There was no documents maintained to track the treatment activities. Some staff went to their own physicians and did not turn in documents.
(F) Infection Control Plan didn't address "conditions such as scabies" .

2. Staff member #2 (Infection Control Officer) indicated in interview beginning at 10:30 a.m. on 4/14/14 that the scabies issue was handled by the CNO because he/she "was busy" with other duties. He/she was not hired for infection control, however this was added after he/she was hired. He/she was hired for quality and has had several duties added. It was "too much" for him/her.

3. Review of CDC document for control and treatment of scabies states under Control and Treatment" on page 1 of 2: ".......Identify and treat all persons (e.g. staff, relatives, patients, etc.) having prolonged, direct skin-to skin contact with an infested person before he/she was treated." CDC guidance for scabies and institutional settings indicates need for active surveillance for effective prevention and control (in addition to treating).

4. Review of infection control meeting minutes (also quality meeting) for December-present indicated the infection control committee did not discuss the scabies issue prior to March 2014 meeting. The meeting for March 25th states "Scabies outbreak on BHS" and "Scabies infestation and treatment on BHS unit in process. Outbreak Investigation Report to be completed and reported in April 2014 Quality Council Meeting." Four (4) staff members had been diagnosed with scabies between 1/23/14 and 2/7/14.

5. CNA job description states under position summary: "Performs various patient care duties and related non-professional services necessary in caring of the personal needs and comfort of the patients." The document states under essential position functions: "Turns, positions and toilets patients........" and "Ambulates patients......."

6. Review of Emergency Department (ED) record for staff member #14 (CNA BHU) indicated he/she was diagnosed and received a prescription for treatment and instructions for scabies at 11:48 a.m. on 1/23/14.

7. Review of staffing documents indicated that staff member #14 was assigned to the BHU as a CNA on 1/23/14 beginning at 7:00 a.m.

8. Review of patients #1-15 medical records (patients on BHU at time of staff member #14 diagnosis in January) lacked evidence that the patients were screened and/or treated for scabies.

9. Review of ED employee charges/tracking, pharmacy documents for medications dispensed to employees, and personnel files indicated the following:
(A) Personnel file review indicated that staff member #B21 (CNA) was treated for scabies on 1/27/14, staff member #B41 (CNA) was treated for scabies on 2/1/14 and staff member #B32 (CNA) was treated for scabies on 2/7/14. The documents lacked evidence that other employees besides staff members 14, B21, and B32 were checked and/or treated for scabies in January and February.
(B) Numerous staff members were treated in March, however, the documents lacked evidence that BHU staff members #B1 (CNA), B2 (RN), B5 (Activities Director), B6 (CNA), B10 (CNA), B12 (LPN), B13 (RN), B14 (CNA), B16 (LPN), B18 (LPN), B23 (CNA), B25 (CNA), B27 (LPN), B30 (RN), B36 (Social Worker), and staff members #9 (RN), 10 (CNA), 11 (CNA), 12 (RN), 13 (CNA) and 14 (CNA) were treated for scabies March-present.

10. Review of documents provided by pharmacy for treatment dispensed to patients for scabies on BHU lacked evidence that patients #1-15 and patients #16, 18-21, 24-27, and 29 through 31 had medications dispensed for scabies treatment.

11. Review of patients #16-30 medical records (patients on BHU when employee treatment began in March) indicated the following:
(A) Patients #16 and #18-31 lacked evidence of screening or treatment for scabies.
(B) Patient #17 medical record had evidence of screening with a rash found and treatment for scabies but lacked an order for the treatment.

12. Staff member #7 (Medical Records Supervisor) indicated the following in interview beginning at 3:50 p.m. on 4/14/14:
(A) There was only evidence of 1 patient (patient #17) being treated for scabies in the medical records.

13. Staff member #8 (RN House Supervisor and facility medical record informatics) verified in interview beginning at 4:30 p.m. on 4/14/14 that the medical record information as stated in #8 and #11 above.