**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 23032
Based on observation, interview, and record review, the facility failed to follow its policies relate to controlling the transmission of infections within the hospital.
1. The facility failed to follow its policy related to investigation & handling of an allegation of bed bugs.
2. The facility failed to follow its policy related to infection control during construction.
Findings included:
TX 00329347
1. Bed bug allegation:
Record review of facility policy titled Beg Bug Management Procedure, dated 04-04-2019 showed that:
*Nursing was responsible to check for presence if bedbugs is suspected bed bug is visualized or bed bugs are suspected.
*They were to notify Housekeeping Supervisor and House Supervisor immediately.
*Patient should be showered or bathed, changed into new hospital-laundered clothing and moved to a new room.
*Double bag and seal all patient's clothing & other belongings into a plastic bag.
*Leave room intact without cleaning items to facilitate determination of the extent, if any and to prevent spread of the bugs.
*Close off the room.
*Notify physician.
*Housekeeping will arrange terminal cleaning of the room after the pest control contractor has examined and or treated the room.
During an interview in room [ROOM NUMBER] on 01-16-2020 at at 10:45 AM between Patient ID # 1 and Staff B, Chief Nursing Officer (CNO) , the patient stated her husband had spent the night on the sofa in the room on the night of 1-14-20. She went on to say the next morning, he had bed bug bites all over him-he took pictures. Patient # 1 said she told the nursing staff yesterday about the bug bites. Her husband did not stay last night (Jan. 15) because of the bed bugs. She said they were not too concerned because they knew they would be leaving soon, maybe today.
During the interview, Patient #1's husband came in to the room. Surveyor asked him if the pile of sheets and blankets on the sofa were the same as the sheets he had used the night before last? Both he & the patient said yes; he had left them there.
During an interview on 1-16-2020 at 11:10 AM with Staff B, CNO, she stated the patient should have been relocated yesterday and the bed bug allegation reported to environmental services and infection control for investigation.
The facility took appropriate action immediately following the interview. The patient was relocated , pest control inspected the room and found no visible evidence of bed bugs, but treated the room to be cautious.
2. Construction on patient care unit:
Review of facility policy titled Infection Control During Construction, dated 08/2018 showed that:
*An Infection Control Risk Assessment (ICRA) should be implemented in the design phase;
*Traffic control should include appropriate signage to ensure only authorized personnel can enter construction zone;
*Ventilation: the air within the construction area must be negative with respect to surrounding areas;
*Environmental rounds will be conducted to monitor cleaning, dress, traffic control, signage and other issues.
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Observation on 1-16-2020 at 10:15 AM after exiting elevators, upon arrival to the 2nd floor mother/baby unit; three (3) doorways were noted to be covered in heavy white plastic and taped on the sides with blue tape ; and red tape down the middle.
One of the doorways covered with plastic was labeled with a sign to the right of the door that read: room [ROOM NUMBER]. The plastic covering room [ROOM NUMBER]'s doorway was observed to be slightly billowing outward toward the hallway. There was no signage or any posting to indicate the reason for the doorways to be covered. In addition, there was no signage instructing persons that it was a restricted area.
Interview at the time of initial observation with Contract Staff K, construction worker, he stated the 3 rooms with plastic covered doorways were not currently maintained under negative air pressure rooms. Surveyor and other staff received construction hard hats to inspect behind the door. Behind door to room [ROOM NUMBER] there were 2 construction workers, 3 ladders, and at least 8 ceiling tiles removed. Adjacent areas had plastic sheeting within this room. According to Staff K, construction work on the 3rd floor made it necessary to remove portions of the ceiling in the 3 rooms on the 2nd floor to perform above the ceiling work.
Interview at the time of observation with Staff G, Director of Facilities Management , he stated there was construction taking place on 5 floors of the facility. Surveyor; along with multiple construction staff, facility Staff B, CNO, and Staff C, Quality Director visited 4 other areas of construction taking place: 1rst floor, 3rd floor, 4th floor, and 5th floor. Observation in the other 4 areas construction areas visited, showed an ICRA permit posted ; and documented daily infection control/life safety measures assessed. In addition, negative air pressure was maintained in all 4 areas and being monitored and documented daily.
Review of facility Infection Control Risk Assessment & Permit # 20191101-2, showed the construction locations listed as : 2nd floor MBU & Surgery, Preop; 3rd floor APU & L & D, 4th floor: NICU & MBU and 5th floor : PEDI / PICU ; dated & approved by Staff D, Infection Prevention Director, on 10-28-2019. The Construction activity was assessed as Class D: major duration & construction activities requiring consultative work shifts; and Infection Control Risk level: was assessed as High Risk. Staff D Infection Prevention Director , classified the project as Class IV. Class IV projects require multiple actions to include maintenance of negative air pressure within the work site.
During an interview on 01-16-2020 at 1:15 PM with Staff D, Infection Prevention Director , she reviewed the ICRA process and policy. She stated the construction area on the 2nd floor, Mother Baby Unit should have been maintained under negative air pressure and had appropriate signage.
