Infection control practices led by officer with no experience; patient not protected from self-injurious behavior

The Centers for Medicare and Medicaid Services (CMS) determined that Millwood Hospital violated the conditions of Medicare participation because its “governing body was not effective in its oversight of the hospital.” Millwood Hospital also fell short of the requirements for patient rights and infection control.

Infection Control

CMS found that Millwood Hospital failed to provide a sanitary environment, including:

A) Handwashing was not performed before/during and after patient care according to infection control standards of practice. B) Soiled items (gloves, Lancets) were stored in a clean bin used for blood glucose monitoring equipment. Glucometers were not sanitized and/or cleaned between patient use. C) Medication room on the Geriatric and PICU (Psychiatric Intensive Care Unit) were soiled/dirty and needed cleaning.

In one case, surveyors pointed out that a staff member did not wash her hands before opening medication packages for a patient. The staff member then “went to the wall mounted hand sanitizer dispenser in the nursing station,” but “could not reach [it]” and proceeded to wipe her hands with a sani-wipe. Investigation of two medication rooms revealed “cabinet shelves were dusty with a collection of debris. The floor was soiled, dirty and stained, caps to multi-dose vials, alcohol pre pads and a package of 4 x 4’s was observed on the floor of the room… The counter surfaces were soiled and dirty… A roll of gauze was on the floor.” An interview with the hospital’s infection control officer revealed “she was new at doing the infection control program… [She] stated the hospital was supposed to provide infection control training for her… [She] stated she had no infection control experience except what she was currently learning.”

Patient Rights

CMS found that Millwood Hospital failed to protect patients’ right to care in a safe environment by failing to intervene in a patient’s self-injurious behavior. The patient was admitted with acute psychosis and a known history of inserting foreign objects into her own rectum, but the hospital “did not order special precautions such as 1:1 supervision or the removal of insertable objects.” The patient was eventually transferred to another hospital for continued psychiatric care with a foreign object still in her rectum. CMS noted:

The surveyor asked Staff #14 whether she considered (Patient #1’s) behavior a self-harm behavior and how leaving the pencil in was keeping the patient safe especially due to her psychotic behavior. Staff #14 stated … she had not thought of it in that way, but agreed inserting objects in the rectum had the potential for injury.”