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Based on observation, interview and document review, the hospital failed to ensure that infection control policies and procedures guided staff and were implemented related to the following:

1. A patient's pattern of refusal related to antibiotics ordered for the treatment of Clostridium difficle (infectious diarrhea, C-diff), was not reported to a patient's Physician for 1 of 30 sampled Patient's (16). The lack of reporting, did not ensure that the patient's full antibiotic course was maintained in an effort to prevent the recurrence or spread of the Patient's C-diff infection.

2. A newly admitted Patient's (17) active diagnosis which included C-diff, was not documented as communicated to the Physician or Infection Preventionist, in accordance with the hospital's infection prevention policy. The lack of policy implementation did not ensure that staff were consistent with the hospital's infection prevention practices.

3. Staff were unable to verbalize proper hand hygiene procedures related to patients placed on C-diff precautions. The lack of hand hygiene awareness did not ensure that staff were consistent with the hospital's infection prevention practices.

Findings:

1. On 7/28/15 at 9:00 A.M., a tour of the medical surgical unit was conducted with the Chief Clinical Officer (CCO). An orange colored sign was observed placed at the entrance to Patient 1's room which read, "Contact Precautions."

On 7/29/15 at 4:00 P.M., a review of Patient 1's medical record was conducted with the CCO.

Patient 16 was admitted to the hospital on 7/3/15 with diagnosis which included C. diff colitis history (Clostridium difficile- infectious diarrhea) per a Physician's (MD) 1, History and Physical dated 7/4/15.

Physician orders dated 7/23/15 included Flagyl (antibiotic) 500 mg by mouth every eight hours, stop after 4 days.

Medication administration records (MAR) reviewed, indicated that Patient 16 refused Flagyl on the following date/times: 7/23/15 at 1:35 A.M., 7:30 A.M., 2:25 P.M. and 7/24/15 at 5:06 P.M.

MD 1's Progress note, dated 7/26/15, included, Clostridium difficile colitis, continue Flagyl (antibiotic).

MD 1's Progress note, dated 7/28/15, included, Patient 16 completed Flagyl.

Bowel regimen documentation indicated that Patient 16 continued to have liquid stools on the following date/times: 7/23/15 at 5:42 A.M., 7/28/15 at 12:00 A.M., 6:10 P.M., and 10:16 P.M.

On 7/29/15 at 4:25 P.M., an interview was conducted with a Registered Nurse (RN) 42. RN 42 stated that, if a patient refused antibiotics, the nurse would call the patient's Physician due to the risk for continuation of the infectious process.

On 7/30/15 at 10:00 A.M., an interview was conducted with MD 1. MD 1 stated that staff had not informed her that Patient 1 had refused 4 doses of Flagyl. In addition, MD 1 stated that it if she had been informed of Patient 16's refusals, the Flagyl treatment course would have continued.

On 7/30/15 at 11:18 A.M., an interview was conducted with RN 43. RN 43 stated that Patient 16 had refused Flagyl two times during her shift. RN 43 acknowledged that according to the MAR, Patient 16 had refused Flagyl four times. RN 43 acknowledged that there was no documented evidence in Patient 16's medical record, to indicate that a physician or MD 1 had been informed. RN 43 was not aware of any policy and procedure related to informing the physician when patient's refuse antibiotics, however; acknowledged that, had MD 1 known of Patient 16's refusals of Flagyl, the patient's antibiotic treatment would have continued.

On 7/30/15 at 11:30 P.M., the hospital's policy and procedure titled "Administration of Medications" dated, 05/2015 was reviewed with the CCO . The policy did not guide staff or include parameters of if/when to call a physician related to patient refusal patterns of specific medications which potentially lacked efficacy if not administered as ordered. The CCO acknowledged that the lack of reporting, did not ensure that the patient's full antibiotic course was maintained in an effort to prevent the recurrence or spread of the Patient's C-diff infection.

2. On 7/28/15 at 12:00 P.M., a tour of the medical surgical unit was conducted with the Chief Clinical Officer (CCO). An orange colored sign was observed placed at the entrance to Patient 17's room, which read, "Contact Precautions."

On 7/28/15 at 12:05 P.M., an interview was conducted with a Registered Nurse (RN) 44. RN 44 stated that she thought the orange signage was placed for clostridium difficile (C-diff, infectious diarrhea) precautions for Patient 17, however; she had not been informed by staff, if the patient had a history of C-diff or had an active diagnosis upon admission.

On 7/28/15 at 12:25 P.M., a review of Patient 17's medical record was reviewed with the Chief Clinical Officer (CCO) and a Nurse Supervisor RN 45. During the review, RN 45 stated that upon admission, the RN reviews the hospital's PACE Re-Assessment (current/active diagnosis obtained from referring facility-PACE) for the patient and if there is documentation related to any infectious process, staff informed the physician and implemented the hospital's infection control policies.

Patient 17 was admitted to the hospital on 7/24/15 according to the History and Physical dated 7/25/15.

Patient 17's PACE, dated 7/22/15 included documented evidence that Patient 17 had active C-diff.

A Physician's (MD) 2 Consultation Report, dated 7/28/15, indicated " C. difficile colitis diagnosed in 02/2015 with questionable recurrent episode in April." "Monitor closely for recurrent C-diff colitis."

Bowel regimen documentation indicated that Patient 17 had liquid stools on the following date/times: 7/25/15 at 7:21 A.M., 7/26/15 at 6:03 P.M., 7/27/15 at 11:12 A.M. and 7/29/15 at 9:34 A.M.

On 7/29/15 at 2:00 P.M., a review of Patient 17's medical record, the hospital's infection control policy titled "Transmission Based Precautions" dated 8/31/13 was reviewed during an interview with the CCO, Infection Preventionist (IP) and Interim Infection Preventionist (IIP). The policy indicated, Patients with documented or suspected infection pathogens, are placed on contact, droplet, or airborne precautions to prevent transmission. In addition, the policy included implementation of the following procedures:

1. Notify the designated Infection Preventionist Nurse of the suspected infectious or communicable disease.
2. Review signs and symptoms to determine if they meet the definition without confirmation and the type of precautions recommended.
3. Initiate surveillance procedures.
4. Contact the patient's physician to obtain orders for culture/confirmation of infectious disease and for isolation if needed.
5. Notify family/responsible party.
6. Update care plan.
7. Communicate to staff isolation interventions.

On 7/29/15 at 2:30 P.M., an interview was conducted with the CCO, IP and IIP. The CCO, IP and IIP acknowledged that Patient 17 had documented evidence included in the PACE upon admission and that there was no documented evidence in Patient 17's medical record that the Transmission Based Precautions had been implemented. In addition, the CCO, IP and IIP acknowledged that the policy did not guide staff in maintaining accountability for communication related to patients PACE documentation on admission. The lack of communication, did not ensure that The lack of policy implementation did not ensure that staff were consistent with the hospital's infection prevention practices in accordance with their Transmission Based Precautions policy and procedure.

3. On 7/28/15 at 8:35 A.M., a tour of the medical surgical unit was conducted with the Chief Clinical Officer (CCO).

On 7/28/15 at 8:45 A.M., an interview was conducted with the CCO and a Certified Nursing Assistant (CNA) 46. CNA 46 stated that hand hygiene practices for patient's with Clostridium difficile (C-diff) infection, included using alcohol based hand rub (ABHR). In addition, CNA 46 stated that part of her annual in-service education and skills training included infection control policies and procedures.

On 7/28/15 at 9:00 A.M., an interview was conducted with the CCO and CNA 47. CNA 47 stated that hand hygiene practices for patient's with Clostridium difficile (C-diff) infection, included using alcohol based hand rub (ABHR). CNA 47 stated that part of her annual in-service education and skills training included infection control policies and procedures.


On 7/28/15 at 2:20 P.M., an interview and review of the hospital's policy and procedure titled "Management Guidelines of the Patient with Clostridium Difficile Infection" dated 08/2014, was conducted with the Infection Preventionist (IP), Interim Infection Preventionist (IIP), Director Quality Risk (DQR) and the CCO. The Policy included, hand hygiene with soap and water should be the preferred method before exiting the room of a patient with C-diff. The IP, IIP, DQRM and CCO acknowledged that staff were unable to verbalize proper hand hygiene procedures related to patients placed on C-diff precautions. The lack of hand hygiene awareness did not ensure that staff were consistent with the hospital's infection prevention practices in accordance with their policy and procedure.