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Based on observations, record review and interviews, the Hospital failed to ensure that infection control protocols were implemented for 4 Patients (#4, #5, #8 and #9) from a total sample of 10 Patients.
Findings include:

1. The Hospital approved, Contracted Dialysis Service's policy titled "Changing Central Venous Catheter (CVC) Dressing," date of review of 1/16/09 included:

"Step 3. Remove old dressing to assess for signs of infection. Discard old dressing and gloves in appropriate waste container;

Step 4. Wash hands and (then) don clean or sterile gloves, per Hospital policy."

Review of the ChloraPrep skin disinfectant manufacturer's directions for use indicated to "allow the solution to dry for 3 minutes."

For Patient #5, observations of a CVC dressing change in Dialysis Room 318, on 9/23/14 at 10:00 A.M., at the Lowell General Hospital-Saints Campus, indicated the following:

After removing and disposing of the old CVC dressing, Contract Service Dialysis Nurse #1 failed to wash her hands before donning sterile gloves as required.

Contract Service Dialysis Nurse #1 failed to adhere to the manufacturer's directions for use of the ChloraPrep skin disinfectant. Contract Service Dialysis Nurse #1 failed to allow the ChloraPrep skin disinfectant solution to dry for 3 minutes before applying the new CVC dressing. Contract Service Dialysis Nurse #1 said that the ChloraPrep skin disinfectant only needed to dry for one minute before applying the CVC dressing.

2. Review of the Hospital policy for isolation precautions indicated that "contact precautions were required for a patient known or suspected to be infected with micro-organisms that could be spread by direct or indirect patient contact. A protective gown and gloves were required to be worn upon entering the patient's room."

Review of the Hospital's Hand Hygiene Policy, indicated that "hands were to be decontaminated with alcohol based hand rub or soap and water as follows:
Before and after direct contact with patients; entering and leaving the treatment area; before performing any invasive procedure such as vascular access or administering intravenous medications; and immediately after removing gloves."

Contract Service Dialysis Nurse #1 was interviewed on 9/23/14 at 10:10 A.M., in Dialysis Room 318, at the Lowell General Hospital-Saints Campus. Contract Service Dialysis Nurse #1 said that Patient #4 (who was in Dialysis Room 317), was on contact precautions, requiring all staff who entered Room 317 to wear gloves and a protective gown.

Observations in Room 317, at 10:35 A.M. on 9/23/14, indicated that a Materials Management Staff Member had entered the room and was restocking the clean supply closets. The Materials Management Staff Member was not wearing a protective gown and gloves and had also pushed a cart containing sterile and clean supplies into the contact precautions room. During the observation the Materials Management Staff Member said that he never wore gloves here (in the Dialysis Room).

Observations at 10:45 A.M. on 9/23/14, indicated that a Contact Precautions sign was posted on the outside door frame of Room 317. The sign contained specific directions that staff and visitors were to follow before entering the room (wear a gown and gloves). The Materials Management Staff Member failed to follow the posted directions.

Additionally, the Materials Management Staff Member failed to perform hand hygiene before entering and after leaving Room 317, as required by Hospital policy.

During the observation, the Director of Quality and Risk said that the Materials Management Staff Member failed to adhere to Hospital policy and that the cart and the sterile supplies were now considered contaminated.

3. For Patient #8, observation on 9/24/14 at 9:50 A.M. and again at 9:57 A.M., indicated that Contract Service Dialysis Nurse #4 twice failed to perform hand washing before donning gloves.


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4. The Surveyor observed the initiation of a dialysis treatment for Patient #9 in the Intensive Care Unit of the Saint's campus at 9:34 A.M. on 9/24/14. Patient #9 was on Contact Precautions for a multi-drug resistant organism. Contract Service Dialysis Nurse #3 was observed exiting Patient #9's room twice to retrieve additional supplies to initiate the dialysis treatment. Contract Service Dialysis Nurse #3 twice failed to dispose of the protective gown and instead reused the protective gown twice.

The Infection Prevention Nurses were interviewed at 1:00 P.M. on 9/24/14. Infection Preventionist #1 said there was to be no re-use of personal protective equipment.

The manufacturer's directions for use were reviewed on 9/25/14. The protective gown (Medi-choice #77755) was a single use only item.

Based on observations, record review and interviews the Hospital failed to consistently adhere to the their policies and procedures for hand hygiene, use of personal protective equipment, discarding of expired sterile supplies, monitoring of refrigerator temperatures and controlling risks contributing to healthcare-associated infections.

Findings include:

1. The Lowell General Hospital Campus Operating Room was toured at 8:30 A.M. on 9/25/14. The Surveyor observed a sterile Thoracotomy kit in the anesthesia workroom that had expired in 2012 and a sterile Central Venous kit in the Operating Room that expired in 2011.

The Lowell General Hospital Campus Intensive Care Unit was toured at 10:55 A.M. on 9/25/14. The Surveyor observed sterile Cardiac Output Pressure Tubing that expired on 7/29/14.

2. The Lowell General Hospital Campus Endoscopy Unit was toured at 9:00 A.M. on 9/25/14. The medication refrigerator log indicated temperatures were monitored Monday through Friday, when the Unit was open. The medication refrigerator temperature was not monitored during the days the Unit was closed. The medication refrigerator contained Tuberculin Purified Protein Derivative that must be stored at 2? to 8?C (35? to 46?F) to ensure efficacy. According to The Joint Commission standard, the monitoring method must track temperature in an ongoing fashion to indicate whether or not internal temperature has deviated from the required ranges for all drugs stored.



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3. Observation in Dialysis Room 318, at 10:30 A.M. on 9/23/14 at the Lowell General Hospital-Saints Campus, indicated that the alarm of the medication refrigerator had been turned off. Contract Service Dialysis Nurse #1 said that she did not know how long the alarm had been shut off. The Director of Quality and Risk said that since the Dialysis Room did not operate 24 hours a day, 7 days a week, the alarm was important to alert the staff that power to the medication refrigerator was not functioning and without refrigeration the medications would lose their effectiveness. Additionally, the Director of Quality and Risk said that the medication refrigerator was not electronically monitored by the hospital Pharmacy. Therefore the alarm was integral to the proper maintenance of the refrigerator temperature.

The Dialysis Medication Refrigerator contained the medications Aranesp (treats anemia) and CathFlo Activase (dissolved blood clots in central venous catheters). Both medications required refrigeration to maintain potency.

Review of the medication refrigerator temperature log indicated that the refrigerator was to be maintained between 35 and 46 degrees Fahrenheit. Observation at 10:30 A.M. on 9/23/14, indicated that the refrigerator temperature was 30 degrees Fahrenheit, five degrees below the required range. Observation again at 11:10 A.M. on 9/23/14 indicated that the refrigerator temperature was 31 degrees Fahrenheit, 4 degrees below the required range.

Observation of the Dialysis Medication Refrigerator on 9/24/14 at 8:30 A.M., indicated the alarm was still turned off. Contract Service Dialysis Nurse #4, said that the alarm was off when she arrived at work at 6:30 A.M.

4. The Lowell General Hospital Campus Emergency Department was toured from 7:45 A.M. to 9:00 A.M. on 9/25/14. The Surveyor observed the following:

a. A large amount of tape residue was observed on the Intravenous Cart, the Pediatric Airway Cart, and the electrocardiogram machine. The Emergency Department Nurse Manager said that tape residue prevents effective disinfection of patient equipment between patients, thereby providing a risk for cross-contamination and staff should not be putting tape on the Emergency Department equipment.

b. The patients' food refrigerator freezer in the Team C and E area lacked a thermometer. Review of the refrigerator temperature log indicated that it lacked temperature readings for the freezer. Six half-gallon containers of ice cream were stored in the freezer. The Emergency Department Manager said that the freezer temperature had never been monitored.

c. The temperature of the patients' food refrigerator freezer in the Team D area was not monitored and lacked a thermometer. Review of the refrigerator temperature log indicated that it lacked temperature readings for the freezer. Additionally, the freezer contained a large build-up of ice and needed defrosting. The Emergency Department Manager said that monitoring food refrigerator temperatures was the responsibility of the Dietary Department.

5. The Lowell General Hospital Campus Cardiac Catheterization Unit was toured from 10:00 A.M. to 11:15 A.M. on 9/25/14. The Surveyor observed the following:

a. Observation in the Cardiac Catheterization procedure room at 10:10 A.M. on 9/25/14, indicated that the Scrub Technician (handed the sterile instruments and supplies to the operating physician during the procedure), wore her mask below her nose. The mask was not secured over her nose and mouth, providing a risk of cross-contamination of the sterile instruments and supplies from her exhaled breath. When brought to the attention of the Nursing Director of Cardio-Vascular Services, the Nursing Director said that the eye protection shield, that was attached to the mask,covered the Scrub Technician's mouth. The Nursing Director did not express understanding that the eye shield did not fit securely over the Scrub Technician's nose and mouth and did not function as a filter for the Scrub Technician's breath, in order to reduce the risk of cross-contamination.

b. Observation in the Cardiac Catheterization procedure room at 10:45 A.M. on 9/25/14, indicated that the Scrub Technician failed to follow manufacturer's directions for use of the disinfectant used to disinfect Cardiac Catheterization equipment between patients. Review of the manufacturer's directions for use indicated that the equipment surfaces must remain visibly wet for 2 minutes. Observation of disinfection of the Cardiac Catheterization equipment indicated that the equipment was only visibly wet for 40 to 50 seconds.