HospitalInspections.org

Based on review of facility policy, review of an Isolation Status Report, medical record review, observation, and interview, the facility failed to implement infection control measures for one patient (#5) of five sampled patients.

The findings included:

Review of facility policy titled Infection Control dated November 2010, revealed, "...Standard Precautions is a method of using appropriate barriers to prevent the transmission of infectious organims and applies to...blood...all body fluids...regardless of whether they contain visible blood..."

Review of facility policy titled Infection Control dated May 2010, revealed, "...Transmission Based Precautions are always over and above Standard Precaution. Contact Precautions is the most common Transmission Based Precaution, and is a method designed to reduce the risk of transmission of micro-organisms by direct or indirect contact...Indirect contact transmission involves contact of a susceptible host with a contaminated intermediate object, usually inanimate, in the patient's environment..."

Review of an Isolation Status report dated November 14, 2012, revealed, "...(Patient #5) Isolation contact...adm w/ESBL (admitted with Extended-Spectrum Beta Lactamase- an antiobiotic resistant organism that causes hospital acquired infections)..."


Patient #5 was admitted to the facility on November 5, 2012, with diagnoses including Pannicular Abscess.

Medical record review of an Operative Report dated October 29, 2012, revealed, "...sepsis from infected pannicular abscess..."

Medical record review of a physician's order dated November 5, 2012, revealed, "wound care eval & tx (evaluation and treat) per protocol."

Medical record review of a Wound Clarification/Agreement dated November 6, 2012, revealed, "present on admission...RLQ (right lower quadrant) abdominal surgical site full thickness..."

Observation on November 14, 2012, at approximately 3:10 p.m., revealed the patient in bed and a wound vaccum cannister on the floor next to the patient's bed. Continued observation revealed tubing drained blood-tinged fluid from the patient into the cannister on the floor.

Observation and interview with the Director of Quality/Risk Management on November 14, 2012, at 3:20 p.m., revealed the cannister on the floor, and placement of the cannister depended on gravity and location of a patient's wound.

Interview with the facility's Infection Control Preventionist on November 14, 2012, at 4:00 p.m., in an administrative office, revealed the cannister should not be on the floor. Continued interview confirmed the facility failed to position the cannister on a clean surface closer to the patient's wound for Patient #5 on November 14, 2012.