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Based on record review, observation and interview, the hospital failed to meet the Condition of Participation for Infection Control as evidenced by:

1) The failure to ensure: a) The room of a patient infected with Clostridium Difficile was cleaned/disinfected by agents that were effective against the Clostridium Difficile toxin; b) Staff donned the appropriate PPE for patients on isolation precautions; c) Staff cleaned/disinfected the multiple-use glucose monitor after each patient use, and d) Staff adhered to acceptable hand hygiene practices. (See findings at tag A0749)

2) The failure of the Chief Executive Officer, Director of Nursing, and the Medical Staff to ensure housekeeping practices were implemented to prevent transmission of infectious agents related to the use of a disinfecting agent which was not a spore-killing disinfectant for Clostridium Difficile in the patient room of a patient (#17) who was positive for Clostridium Difficile. (See findings at tag A0756)

Based upon record review and interviews, the hospital failed to ensure the Quality Assurance/Performance Improvement plan had ongoing activities related to monitoring medication errors. This was evidenced by the failure to conduct medication error reviews from January 2017 to August 2017.
Findings:

Review of the Quality Assurance data from January 2017 to September 2017 revealed medication errors were only tracked and analyzed for August and September 2017.

Interview on 10/04/17 at 11:05 a.m. with S1Administrator and S2RN/DON revealed when asked if medications errors were reviewed through the QA/PI Program from January 2017 through July 2017, S2RN/DON replied the former DON had not reviewed the medication errors. Further interview with S2DON at this time revealed that there was no documented evidence that the medication errors that were identified in August and September 2017 had been investigated to determine cause in order to prevent further errors.

Based on record review and interview, the hospital failed to ensure that drugs were administered in accordance with physician orders as evidenced by failure to administer medications as ordered by the physician for 2 of 3 patients reviewed for antibiotic administration in a total sample of 20 (Patient #14, 17).
Findings:

Review of the policy titled, Medication Administration, presented as current by S2DON revealed in part that time critical scheduled medications are those for which an early or late administration of greater than 30 minutes might cause harm or have significant negative impact on the intended pharmacological effect. Examples of time critical scheduled medications include antibiotics, which are to be administered within 30 minutes before/after scheduled dose.

Patient #17
Review of the medical record for Patient #17 revealed a diagnosis of Clostridium Difficile Colitis. Review of the physician orders revealed an order written on 09/27/17 for Vancomycin 250mg/5mL, 5mL to be administered every 6 hours (9AM/3PM/9PM/3AM).

On 10/02/17 at 3:10 p.m., review of the patient's MAR revealed no documented evidence that Vancomycin was administered at 9 a.m. that morning as ordered.

On 10/03/17 at 10:40 a.m., review of the patient's MAR revealed no documented evidence that Vancomycin was administered at 9 a.m. that morning. At that time, the surveyor asked the S2DON if the automated medicine cabinet could perform a reconciliation to ensure that the medication had been obtained from the medication cabinet in order to be given by the nurse. She stated that the medication was refrigerated so reconciliation was unable to be performed. At that time, the surveyor requested to observe the medication bottle. S2DON was unable to locate the patient's Vancomycin medication.

On 10/03/17 at 11:00 a.m., interview with S5LPN revealed that she had not administered Patient #17's 9 a.m. Vancomycin dose that morning.

On 10/03/17 at 11:15 a.m., S5LPN informed the surveyor that she had just administered Patient #17's Vancomycin dose. At that time, observation revealed that S5LPN initialed on the patient's MAR that she had administered the Vancomycin at 9 a.m.

On 10/03/17 at 4:45 p.m., observation of Patient #17's MAR revealed no documented evidence that the 3:00 p.m. dose of Vancomycin had been administered.


Patient #14
Review of the Medication Incident Summary Report provided by S2DON revealed that Patient #14 was listed on this report. Review revealed that on 09/17/17, the patient's Levaquin antibiotic was not documented as given/administered at 9:00 a.m. and Maxipime antibiotic was not documented as given/administered at 4:00 p.m.

On 10/04/17, review of the patient's MAR dated 09/17/17 revealed documentation that the Levaquin was administered at 9:00 a.m. and the Maxipime was administered at 4:00 p.m.

On 10/04/17 at 1:50 p.m., interview with S2DON confirmed the documentation of the medication administration on 09/17/17. She stated that the nurse must have gone back and charted the antibiotics as given after she had talked to her about the error. When asked if the medication was actually given to the patient on 09/17/17, she stated she did not know.

Based on record review and interview, the hospital failed to ensure all medication orders (except in emergency situations) were reviewed by a pharmacist before the first dose was dispensed (review for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications).
Findings:

Review of the Louisiana Administrative Code, Title 46 Professional and Occupational Standards, Part LIII Pharmacist, Chapter 15 Hospital Pharmacy, Section: 1511: Prescription Drug Orders, Item A. The pharmacist shall review the practitioner's medical order prior to dispensing the initial dose of medication, except in cases of emergency.

Review of the hospital policy titled, Medication Administration, revealed in part that medications should be readily available in the medication room or automated medication dispensing cabinet.

On 10/02/17 at 12:50 p.m., observations in the medication room revealed patient medications were stored in an automated medication dispensing cabinet. Interview with S4RN, at this time, revealed that when a new medication order is obtained for a patient, the off-site pharmacy is notified and the pharmacists have two hours to review the medication and program the medication in the automated dispensing cabinet. When asked if the nursing staff is able to override the system and obtain medications prior to the pharmacist reviewing and loading the medication in the automated cabinet, she stated yes. She further stated that she frequently overrides the system for new medication orders because if she waits the full two hours for pharmacy to program them in the dispenser, she would forget to give the medication.

On 10/03/17 at 9:00 a.m., interview with S7Pharmacist revealed that the nursing staff is able to override and obtain new medication orders from the automatic dispensing cabinet without a pharmacist performing a first dose review of the new medication. When asked if this was a normal occurrence, she stated yes.

On 10/04/17 at 2:00 p.m., interview with S2DON confirmed that she was aware of the issue that nurses are overriding the automated medication dispensing system in order to administer new medications prior to a first dose review by a pharmacist. She further stated that the nurses did not like to wait the two hours that it sometimes takes for the pharmacist to load the medication profile in the dispensing cabinet.

Based on record review, observation and interview, the hospital failed to ensure the infection control officer implemented measures for controlling infections and communicable diseases as evidenced by:

1) Failing to ensure the room of a patient infected with Clostridium Difficile was cleaned/disinfected by agents that were effective against the Clostridium Difficile toxin,

2) Failing to ensure that staff donned the appropriate PPE for patients on isolation precautions,

3) Failing to ensure that staff adhered to acceptable infection control practices relative to hand hygiene and cleaning/disinfecting glucose monitor.

Findings:

1) Failing to ensure the room of a patient infected with Clostridium Difficile was cleaned/disinfected by agents that were effective against the Clostridium Difficile toxin.

Review of the hospital policy titled, Management of Patients with Clostridium Difficile, presented as current by S2DON, revealed in part that Maximum Contact Precautions would be instituted. Healthcare personnel will wash hands with soap and water prior to and after direct patient care activities or interaction with any potentially contaminated environmental surfaces or items. Gloves will be worn during any patient care activities or interaction with any potentially contaminated environmental surfaces or items. The environment (patient room) and reusable items must be thoroughly cleaned with a chlorine-containing cleaning agent or other sporicidal agent.

Review of the medical record for Patient #17 revealed an admit date of 09/27/17 with diagnoses including Clotstridium Difficile colitis and gastroenteritis. Review of the admit physician orders revealed an order for the patient to be placed on contact precautions.

On 10/02/17 at 1:25 p.m., observation revealed S6Housekeeper exited Patient #17's room without gloves on. She was then observed to remove the reusable mop head with her bare hands and put in a plastic bag on her cart. Interview with S6Housekeeper at this time revealed that she cleaned all patient rooms with the same chemicals. She stated that she used Stride to mop the floors with and used Virex on all other areas in the rooms. The surveyor asked to see the bottle of Virex and she removed it from her cart. Observation of the spray bottle revealed it was not labeled with the chemical in the bottle. When asked if anything extra was cleaned in the rooms of the patients who had Isolation Precaution stickers on their doors, she stated that she used bleach on the door handles in those rooms. When asked to see the bleach that she used, she stated there was none on her cart. Observations on the housekeeping cart revealed that a bristle broom was on the cart. When asked if this broom was used on all patient rooms, including the patients on Isolation, she stated yes. She further stated that this broom was not disinfected between use in each patients' room.

On 10/02/17 at 3:30 p.m., S2DON provided the manufacturers information regarding the Stride and Virex cleaning agents. Review of this information revealed that they were not effective Clostridium Difficile toxin.

On 10/03/17 at 8:15 a.m., S3Director of Clinical Services confirmed that the chemicals (Stride and Virex) being used to clean the rooms of patients diagnosed with Clostridium Difficile infections were not effective against that toxin. She stated that the hospital would now be using Avert, which was effective against Clostridium Difficile.

On 10/03/17 at 10:20 a.m., interview with S6Housekeeper revealed that she now had a new cleaning agent on her cart that she used on the rooms with patients diagnosed with Clostridium Difficile. When asked to see the bottle, she removed a bottle of Avert. There was no spray nozzle on the bottle. When asked how she used this chemical, she stated that she mixes a little Avert with a little water, but was not sure of the exact measurements. She further stated that someone from the host hospital had brought her the chemical.

On 10/03/17 at 10:45 a.m., interview with S2DON revealed that she was currently going to all staff and inservicing them on the new chemical (Avert) used to clean rooms of patients diagnosed with Clostridium Difficile. When asked if the Avert solution was to be mixed with water, she stated that she did not know. When asked what the manufacturers recommendations were regarding contact time, she stated she did not know.

On 10/03/17 at 11:30 a.m., interview with S1Administrator revealed that the housekeeping supervisor from the host hospital brought the bottle of Avert to S6Housekeeper the day prior. When asked if S6Housekeeper had been instructed on the manufacturers recommendations for the correct use of the chemical, she stated that she thought that the housekeeping supervisor from the host hospital had done that. When asked if she or anyone from this hospital had instructed S6Housekeeper, she sated no.


2) Failing to ensure that staff donned the appropriate PPE for patients on isolation precautions

Review of the hospital policy, titled Isolation Precautions, presented as current by S2DON, revealed in part that gown and gloves will always be worn when entering the room of a patient designated as requiring Maximum Contact Precautions. Gowns should fully cover torso from neck to knees, arms to end of wrists, and wrap around the back; fasten in back of neck and waist.

On 10/03/17 at 11:10 a.m., observation revealed S5LPN entered Patient #17's room with gloves and gown. The gown was observed to be untied at the neck and the back and gaping open.

On 10/03/17 at 5:00 p.m., observation revealed S9LPN donned gloves and placed on a gown prior to entering Patient #17's room. The gown was not tied at the neck or back and was blowing as she walked.

On 10/04/17 at 10:50 a.m., observation revealed S8LPN entered Patient #17's room without gloves or gown. He was observed to touch the patient and the patient's IV pump. Upon exiting the room, interview with S8LPN revealed that he was aware that the patient had Clostridium Difficile infection and was on contact precautions. When asked why he did not wear the proper PPE, he stated that he was just too rushed.


3) Failing to ensure that staff adhered to acceptable infection control practices relative to hand hygiene and cleaning/disinfecting glucose monitor.

On 10/03/17 at 4:35 p.m., observation revealed S5LPN entered Patient #18's room to perform a fingerstick glucose check. Hand hygiene was not performed prior to entering the room. Upon entering the room, she applied gloves and checked the patient's glucose with the glucose monitor. She then removed her gloves in the patient's room, exited the room, replaced the glucose monitor back on the charging station in the nurses station and then sat in the chair to begin charting. Hand hygiene was not performed and the glucose monitor was not disinfected prior to placing it back on the charging station.

On 10/03/17 at 4:45 p.m., observation revealed S4RN was in the nurses station wearing gloves, gathering up supplies to perform a glucose check. Further observations revealed that S4RN entered Patient #16's room with the same gloves on and proceeded to flush and draw blood from the patient's central line. She was then observed to lean over the biohazard container on the wall and squirt blood from the syringe needle onto the stick in the glucose monitor. The monitor gave an error message. At that time, S4RN removed her gloves, exited the room and went to the nurses station. She was observed to lay the glucose monitor on the desk at the nurses station and begin charting. Hand hygiene was not performed and the glucose monitor was not disinfected.

Based upon observations, cleaning agents manufacturers information, and interviews, the Chief Executive Officer, Medical Staff, and Director of Nursing Services failed to ensure housekeeping practices were implemented to prevent transmission of infectious agents. This was evidenced by the use of a disinfecting agent which was not a spore-killing disinfectant for Clostridium Difficile in the patient room of a patient (#17) who was positive for Clostridium Difficile.
Findings:

Review of the hospital policy titled, Management of Patients with Clostridium Difficile, presented as current by S2DON, revealed in part that Maximum Contact Precautions would be instituted. Healthcare personnel will wash hands with soap and water prior to and after direct patient care activities or interaction with any potentially contaminated environmental surfaces or items. Gloves will be worn during any patient care activities or interaction with any potentially contaminated environmental surfaces or items. The environment (patient room) and reusable items must be thoroughly cleaned with a chlorine-containing cleaning agent or other sporicidal agent.

Review of the medical record for Patient #17 revealed an admit date of 09/27/17 with diagnoses including Clostridium Difficile colitis and gastroenteritis. Review of the admit physician orders revealed an order for the patient to be placed on contact precautions.

On 10/02/17 at 1:25 p.m., observation revealed S6Housekeeper exited Patient #17's room without gloves on. She was then observed to remove the reusable mop head with her bare hands and put in a plastic bag on her cart. Interview with S6Housekeeper at this time revealed that she cleaned all patient rooms with the same chemicals. She stated that she used Stride to mop the floors with and used Virex on all other areas in the rooms. The surveyor asked to see the bottle of Virex and she removed it from her cart. Observation of the spray bottle revealed it was not labeled with the chemical in the bottle. When asked if anything extra was cleaned in the rooms of the patients who had Isolation Precaution stickers on their doors, she stated that she used bleach on the door handles in those rooms. When asked to see the bleach that she used, she stated there was none on her cart. Observations on the housekeeping cart revealed that a bristle broom was on the cart. When asked if this broom was used on all patient rooms, including the patients on Isolation, she stated yes. She further stated that this broom was not disinfected between use in each patients' room.

On 10/02/17 at 3:30 p.m., S2DON provided the manufacturers information regarding the Stride and Virex cleaning agents. Review of this information revealed that they were not effective for killing Clostridium Difficile spores.

On 10/03/17 at 8:15 a.m., S3Director of Clinical Services confirmed that the chemicals (Stride and Virex) being used to clean the rooms of patients diagnosed with Clostridium Difficile infections were not effective against that toxin. She stated that the hospital would now be using Avert, which was effective against Clostridium Difficile.

On 10/03/17 at 10:20 a.m., interview with S6Housekeeper revealed that she now had a new cleaning agent on her cart that she used on the rooms with patients diagnosed with Clostridium Difficile. When asked to see the bottle, she removed a bottle of Avert. There was no spray nozzle on the bottle. When asked how she used this chemical, she stated that she mixed a little Avert with a little water, but was not sure of the exact measurements. She further stated that someone from the host hospital had brought her the chemical.

On 10/03/17 at 10:45 a.m., interview with S2DON revealed that she was currently going to all staff and inservicing them on the new chemical (Avert) used to clean rooms of patients diagnosed with Clostridium Difficile. When asked if the Avert solution was to be mixed with water, she stated that she did not know. When asked what the manufacturers recommendations were regarding contact time, she stated she did not know.

On 10/03/17 at 11:30 a.m., interview with S1Administrator revealed that the housekeeping supervisor from the host hospital brought the bottle of Avert to S6Housekeeper the day prior. When asked if S6Housekeeper had been instructed on the manufacturers recommendations for the correct use of the chemical, she stated that she thought that the housekeeping supervisor from the host hospital had done that. When asked if she or anyone from this hospital had instructed S6Housekeeper, she sated no.