DEPARTMENT OF SOCIAL AND HEALTH SERVICES BEHAVIORAL HEALTH AND SERVICE INTEGRATION ADMINISTRATION - Western State Hospital 9601 Steilacoom SW Tacoma, WA 98498~7213 - November 20, 2015 Marie Fe Yamada, RN MSN CMS Division of Survey, Certi?cation, and Enforcement 701 Fifth Avenue, Suite 1600 Seattle, WA 98104 I Email: marieyamada?cms.hhs.gov Elizabeth Gerdon, RN, MN Manager, Hospital Survey Team Depaltment of Health, HSQA Office of Investigation Inspection PO Box 47874 Olympia, WA 98504-7874 Elizabeth.gordon@doli.wa.gov Dear Marie Fe Yamada and Elizabeth Gordon; For the purposes of providing a background reference to this letter, the following events are relevant: Westem State Hospital (WSH) received an unannounced on?site survey from DOH and CMS on October 26, November 5, 2015. During the course of this survey, the ?ndings determined conditions existed that posed an immediate and serious threat to patient safety. The Immediate Jeopardy (II) status was not removed by the end of the survey. 0 On November 16, 2015, WSH submitted IJ Abatement Plans for each individual determination that was made on behalf of CMS. 0 On November 18, 2015, CMS conducted a follow-up teleconference and requested from WSH additional information speci?c to each WSH IJ Abatement Plan. As a result, WSH re- submitted six (6) Abatement Plans, with addendums that addressed each CMS request. On November 20, 2015, CMS conducted a follow-up teleconference and stated upon review, that CMS will be able to accept the Abatement Plans with some changes and clari?cation. CMS requested that the impacted IJ Abatement Plans be resubmitted for review. Therefore, WSH is resubmittng the Abatement Plan Abatement Plan and Abatement Plan #6 for CMS review (see attachments). Thank you for your consideration. Ron Adler, CEO Western State Hospital 'Western State Hospital CMS lJ Abatement Plan #1 Physical Injury and Lack of response to patients needs On 10/ 29/2015 at Washington State Department of Health surveyors determined that a condition existed at WESTERN STATE HOSPITAL, LAKEWOOD, WASHINGTON that posed an immediate and serious threat to patient safety. The facility did not ensure that patients were provided care in a safe setting. The facility needs to respond by developing an effective system-wide plan to remove the immediate risk of harm to patients. a Physical injury to patients and staff 0 Lack of response to patients? needs due to fear of retaliation Strategy/Approach Strategy Approach/Action items Lead Status/ Date Due Completed Staffing Increase staffing by suspending bed expansion to focus on filling existing I vacancies. 1a. WSH has halted expansion of new forensic ward (F3) CEO Completed: Approval received from Secretary of DSHS October 30, 2015. The opening of ward F3 was suspended. 1b. WSH closed a new civil ward (C1) and redeployed staff to permanent vacant positions on other wards. Redeployed 65 staff to fill vacant positions on other wards. 0 Reduced the need to pull staff and use on calls to cover vacant positions. CEO Completed: Ward C1 was closed as of November 9, 2015 and staff has been reassigned to vacant positions elsewhere in the hospital. Staff members are prepared to work on the wards where they are assigned. 2a. Minimized staff pulls from high acuity wards (Forensic Admission wards: F6) and (high acuity civil wards: C3, C4, C5, C6, C8, 58, $10 E4) Staffing Manager November 13, 2015 lJ Abatement Plan #1 (Version 11/20/2015) FINAL Page 1 of 10 2b. OT has been authorized to reduce pulls untii the system is evaluated for effectiveness. CEO November 13, 2015 2c. Stopped Center to Center staff pulls. CEO November 16, 2015 2d. When staff are pulied to unfamiliar wards within the center, they sign off on an "orientation to duty? to include specific instructions about risks and dangers on the ward and reminders about situational awareness at the beginning of their shift with the charge nurse. (Nurse Supervisors) November 13, 2015 2e. When OT is used, use of center based staff will be the priority. OT staff working in unfamiliar wards will sign off an "orientation to duty? to include specific instructions about risks and dangers on the ward and reminders about situational awareness at the beginning of their shift with the charge nurse. November 16, 2015 2f. Charge nurses update the inter-shift reports to include notations of patients with behavioral/safety challenges. (Nurse Supervisors) November 13, 2015 2g. Every staff coming on a ward to provide patient care, reviews and signs the inter?shift report to ensure that all staff are aware of current issues and dangers on the ward. This includes and as well as other disciplines. (Nurse- Supervisors) November 13, 2015 Increase staff situational awareness and de- escalation skills. Staff on Admissions wards are being trained on de?escalation and situational awarenesstechniques. These trainings are conducted on the ward. Staff Development November 16, 2015 Reduce staff fear of retaliation An OFMstaff member is assigned to WSH to assist in reducing fear of retaiiation An introduction about the representative has gone out to all staff to make them aware of how and where to contact him confidentially. The person assigned to this task is known to many staff and is a former WSH employee. Deputy Assistant Secretary November 16, 2015 lJ Abatement Plan #1 (Version 11/20/2015) FINAL Page 2 of 10 This representative is a neutral party, not an employee of DSHS. 5. Medical Director assists in facilitating communication between administration and physicians Dr. Martin accepted the position of interim Medical Director. 0 Dr. Martin facilitates communication between administration and physicians, specificaliy related to clinical issues and clinical oversight of the hOSpital. CEO NOVEmber 4, 2015 6. Increase staffing for most dangerous patients 6a. Wards no ionger ?absorb? the first 1:1 staff for a patient for whom an MD has ordered 1:1 monitoring for DTO (danger to others). This will be evaluated after thirty days. Nursing scheduler RM November 9, 2015. 6b. CFS PERT team supervisor attends morning huddle to receive team assignments to mentor staff assigned to 1:1 patients daily (Monday?Friday). PERT also continues to respond to emergent situations. I On off~shifts the PERT lead makes these assignments in collaboration with the (or designee). Clinical Director and CPS PERT Supervisor November 10, 2015 7. Minimize risk of ongoing violence between patients The RN assesses patients post assault for continued threats of violence toward each other and documents this assessment using the Immediate Post Assault Risk Assessment Tool This tool highlights the risk of verbal and physical violence for ail patients involved in an altercation. It can be used to make recommendations to ensure the safety of patients and staff. Nurse Executive (PNE), RN3 Training began October 2015. To be completed by November 15, 2015. 8. Reserved beds increase patient safety by providing a safe alternative . for separating patients. One emergency safety bed has been established in South, Central, CPS, and East Campuses. 0 After an assault, the medical director or designee and nursing shift managers have the ability to temporarily move patients into reserved safety beds, to increase safety. 0 A procedure is in place which outlines the specific steps to ensure a safe and equitable process. Shift Managers Medical Director November 13, 2015 IJ Abatement Plan #1 (Version 11/20/2015) Page 3 of 10 WSH is taking a proactive approach to address patient violence by eariy risk assessment. WSH increased its efforts to assess violence prior to admission. Admission Coordinators obtain pertinent ciinical information from the referring agency for potential of violence to guide placement on wards. Admission Coordinators November 12, 2015 10. WSH identifies least restrictive measures/ interventions to manage increased risk of violence 10a.For those patients identified as higher risk for violence in CFS, the Supervising RN4, Forensic Ciinical Director and PERT Supervisor work with the treatment team to develop an individualized safety plan. Safety plans address the patient?s risk for violence and identify least restrictive aiternatives for patients exhibiting of aggression. For patients identified as higher risk for violence in PTRC the Supervising RN4 and Center Director work with the treatment team to develop an individualized safety plan. Safety plans address the patient?s risk for violence and identify least restrictive alternatives if the patient exhibits of aggression. CFS Clinical Director and PERT Supervisor Supervising Completed: November 6, 2015 lJ Abatement Plan #1 (Version 11/20/2015) FINAL Page 4 of 10 10b. For those individuals currently in residence in CFS and assessed as high risk, there is a consultation by the Supervising RN4 and Emergency Response Team to develop a patient-speci?c safety plan based on the identi?ed behavioral antecedents to aggression. For those individuals currently in residence in PTRC and assessed as high risk, there is a consultation by the supervising RN4 and Center Director to develop a patient? speci?c safety plan based on the identified behavioral antecedents to aggression. PERT Supervisor, Supervising RN4 Completed: November 6, 2015 11. Reduce risk prior to patient transfers from CFS to PTRC Transfers from CFS to PTRC do not occur until after a case consultation between the transferring and receiving ward staff. 0 Case consultation includes: physician to physician handoff, identification of patient?s danger triggers, identification of warning signs, and interventions that work to help keep the patient and others safe. During the adjustment period 1:1 staff (if ordered) provide ongoing transitional support to the receiving ward. Transfer Committee Completed: November 6, 2015 12. Independent safety review of the most serious patient to patient assaults DSHS Enterprise Risk management conducts independent reviews of ali patient to patient assault related incidents where patients require Outside medical care. 0 Enterprise Risk Management continues to conduct these reviews for incidents involving patient to staff assaults where staff members require outside medical care. 0 Enterprise risk management team reports to Quality Council which makes necessary improvements to training and practice. These reports fall under the Culture of Safety Reporting and Monitoring Section. Enterprise Risk Management and QM Director November 13, 2015 lJ Abatement Plan #1 (Version 11/20/2015) FINAL Page 5 of 10 13. WSH is implementing a multifaceted approach to immediately improve communication hospital wide. to provide immediate information about current emergent Executive leadership hosted "open communication sessions? three times during the week of November 4, 2015, on all shifts Deputy Assistant Secretary, Center Directors, Director of Communications Completed: First Meetings held on November 5 6, 2015. Monthiy meetings scheduled ongoing. safety issues and to get feedback from staff about safety and communication issues hospital wide. - Once per month, on each shift WSH holds all?staff meetings to ensure open communication. 0 Staff are also invited to provide feedback in writing to the Director of communications. Addendum #1 November 19, 2015 Training is only mentioned for the admission wards. 0 Training wiil start on the admission wards because they are the highest risk for violence; the situational awareness and de-escalation training will be completed on the highest risk wards by Decemberl, 2015. After staff are trained on the admission wards training will continue to all other wards within the hospital; we anticipate that all staff will be trained no later than January 1, 2016. What is the immediate plan to ensure that staff who are transferred from the closed units are trained and competent? All the staff hired for C1 and F3 were either current employees who had been trained and were competent or were new hires and went through New Employee Orientation. in addition, all staff have been oriented to their newly assigned wards. What is the immediate plan to ensure all staff are competent when implementing the newly revised or implemented policies/procedures? e. We have Nurse Managers, Nurse Supervisors, and Clinical Nurse Specialists providing training on the wards for all levels of nursing staff related to all changes in policies and procedures. Pians to improve patient safety and reduction in seclusion and restraint as well as expectations applicable to physicians have been shared with the medical staff by the Medical Director. This has occurred in multiple face to face meetings between medical staff and Medical Director and will continue over the next several weeks. Executive Leadership has also met with social work, rehab and disciplines for the same purpose. IJ Abatement Pian #1 (Version 11/20/2015) FINAL Page 6 of 10 0? The Quality Management Department, in partnership with supervisors, are conducting random in person on~ward audits across the hospital to ensure that the changes are being implemented and to provide coaching for staff who need it. The audits address practice and paperwork changes. A What categories are the 65 staff that were re-assigned from the closed wards? Custodian 1 Licensed Practical Nurse 2 Licensed Practical Nurse 4 Mental Health Technician 1 Mental Health Technician 2 Mental Health Technician 3 Office Assistant Lead Pharmacist Social Worker 4 Registered Nurse 2 11 Registered Nurse 3 Security Nurse 5 Security Attendant 14 comm vi 4 x?i Minimizing staff pulls - can you be more specific on how that will be accomplished? a The intent is to keep as many regularly assigned (those who have more familiarity and experience with the patients on those wards) staff on high acuity wards as possible. Therefore overtime and on call staff will be used to fill vacancies, or increased staff needs on a ward. if staff need to be pulled it will not be from a high acuity ward?0r from outside that center. The Shift Nurse Manager will use these guidelines to fulfill the needs of the center. IJ Abatement Plan (Version 11/20/2015) FINAL - Page 7 of 10 The charge nurse assigns tasks in line with the skilis, abilitiesand relationships that staff have with patients. For example, charge nurses ensure that staff who are most familiar with patients in crisis are assigned to those patients. Evaluation of the overtime authorization but no timeline was given a We monitor use of overtime on an ongoing basis. For instance, we gather data to be reported by ward, center and hospital wide by shift and daily roIEup to'show OT hours used by classification as well as the number of staff on OT who are placed in the highest risk wards from another center. Review of this data wiil confirm that we are meeting the commitments made in the abatement pian and provide information for further adjustment as necessary. 0 We anticipate that overtime use wiil continue. We will evaluate after sixty days to determine whether our current strategy for the use of overtime is effectively addressing the reduction of pulled staff working on unfamiliar wards; adjustments will be made as needed. Stopping center to center staff pulls but that hasn?t addressed the specific assignments of the staff pulls. 0 When a staff is pulled to another ward the Charge Nurse will assign tasks to the employee that has the skills and abilities to perform thatjob and will factor in relationships between staff and patients in staffing assignments. This is in addition to the Orientation to Ward Duties provided by the Charge Nurse. Charge Nurses are to update the Inter-Shift report ?-thought that was already an expectation at the time of survey what steps are ensuring that is happening? 0 This has been the expectation. However, in addition, staff are now required to sign off on the Inter-Shift report and the Charge Nurse ensures staff are aware of changed assignments. The Nurse Supervisor will review and sign the Assignment of Care prior to assumption of duties. The Nurse Supervisor wili make sure the Inter?Shift report is signed by everyone entering the ward to provide patient care. 3 Prior to leaving the ward, any staff member who is aware of a patient safety concern or risk, informs the charge nurse so that concerns can be shared with all staff and included in the next report. It appears that only admission wards are getting trained on de-escalation that needs to be more specific. IJ Abatement Plan #1 (Version 11/20/2015) FINAL Page 8 of 10 a Training will start on the admission wards because they are the highest risk for violence; staff on the highest risk wards will all be trained by December 1, 2015. After staff are trained on the admission wards training will continue to all other wards within the hospital. Staff hospital?wide will receive this training? by January 1, 2016. No time frame given for the completion of individual safety plans. How long after admission? And are safety plans also going to be conducted post~assault if a patient assaults somebody or if the safety risk is assigned? we Information collected by the admission coordinators and recorded in the preadmission information "call sheet? is transmitted to the wards prior to the patient?s arrival. This information is used to guide interaction with the patient upon admission and serves as the basis for articulating the safety plan. 0 Safety plans are completed upon admission (within 24 hours) and updated prior to every Evaluation and Treatment Conference (ETC) which occurs at a minimum of every 90 days, following any episode of actual assault and/or as necessary; for example review of the safety plan are triggered by the observation of escalation, missed or refused medication, threatening episodes or as an outcome of the daily safety huddle necessary updates are made as needed. Nursing completes the initial plan of care which includes the safety plan within 24 hours of admission. The treatment team deveiops a multidisciplinary plan of care which updates the safety plan within 14 days of admission. Morning huddles were mentioned for the PERT Team on CFS but what about the other units? We have morning huddles in all centers. The huddles include at a minimum, the Supervisor, and Center Directors. Cuiture of Safety - OFM Staff member How do we guarantee confidentiality? 0 There will be no intermediary between staff and this individual. Any written information or notes made will not contain any personally identifiable information about staff. Completion of the IPARAT how does that minimize the risk of ongoing violence between patients? It is one of the many pieces of information utilized to evaluate a potential reoccurrence of violence or assaultive behavior between. patients. The IPARAT may result in an update to the safety plan, the behavioral pian, or it may guide decision making to separate patients, transfer patients, utilization of safety beds, to establish 1:1?s. IJ Abatement Plan #1 (Version 11/20/2015) FINAL Page 9 of 10 Assigned safety bed 'per unit how is that to be used to reduce the incidences of assault? Appears to only be deployed after there has been an assault without mention of pre-emptive steps that could be accomplished. 0 These beds can be used to separate patients who have been invoived in assaultive episodes and to diminish escalation ifthreats have been made. It is only one of the strategies that can be used for pre and post assault patient management. 0 Safety beds are a very limited resource and must be used judiciously; we always use safety beds to separate patients in a serious patient to patient assault. Addendum November 20, 2015 We would iike to require at least two trained personnel per shift per ward to remove the immediacy. 0 Western State Hospital will compare training records to staf?ng records to ensure that there are two trained staff on every shift, every ward. We would also like clari?cation on the safety beds. Are they non-permanently assigned beds? a Safety beds are vacant beds within the Center; each center keeps one bed vacant (this is the safety bed: forexample, when a person moves their bed becomes the safety bed) to facilitate emergent movement within the center. When a patient is moved on an emergent 'basis this may become their permanent bed to ensure their safety and the safety of other patients and staff. In some cases, these beds do notconvert to a permanent bed for that patient; the final decision is made based on patient care needs to ensure patient and staff safety. Related to the training issue, our expectation is that any staff providing one-to?one will receive priority and will have received the new training. 0 Staff assigned to 1:15 receive pre-assignment instruction on observation, engagement, and situational awareness. They are a priority for I the new training. IJ Abatement Plan #1 (Version 11/20/2015) FINAL Page 10 of 10 Western State Hospital CMS IJ Abatement Plan #4 Quality Assessment and Performance Improvement 0n 11/2/2015 at Washington State Department of Health surveyors determined that a?condition existed at WESTERN STATE HOSPITAL, LAKEWOOD, WASHINGTON that posed an immediate and serious threat to patient safety. The facility did not ensure that the patients and staff members at Western State Hospital are protected from immediate harm by developing, implementing, and maintaining an effective, ongoing, hospital-wide Quaiity Assessment and Performance Improvement program. The facility must respond by developing and implementing an effective hospital-wide Quality Assessment and Performance Improvement program and remove the immediate risk of harm to patients and staff. I Strategy/Approach Strategy Approach/Action Items Lead Status/ Date Due Completed WSH has adopted a la. The WSH QAPI was approved by the Governing Body on QM Director October 30, 2015 Quality Assessment October 30, 2015 and Performance 0 The QAPI had been disseminated to the Executive Improvement Plan to Leadership Team and Medical Staff. reduce immediate risk to patients and staff through analysis and action. 1b. The QAPI has been introduced to aE] staff. Director November 13, 2015 1c. The QAPI includes the foliowing performance improvement QM Director IOctober 30, 2015 projects a Decrease Patient to Patient Assaults Decrease Patient to Staff Assaults Decrease quarterly rates of seclusion and restraint 0 Increase the rates of active treatment IJ Abatement Plan #4 (Version 11/20/15) FINAL - Page 1 of4 WSH uses Lean tools to address Performance Improvement Projects to ensure multidisciplinary engagement in planning and implementation 2a. The ?rst QAPI Performance Improvement Project Lean workshop (Patient to Patient Assaults) was held on November 2- 3, 2015 and a final action plan was developed resulting from this workshop on November 9, 2015. QM Director November 9, 2015 2b. The action plan resulting from the Patient to Patient Assault workshop has been developed and action steps are under way (See Attached A3 Action Plan). Staff identified many important strategies, for example: 0 On CFS, the Clinical Director and Director of Security are piloting a project to appoint a safety officer from each ward to identify and address safety concerns. QM Director November 9, 2015 and ongoing projects 2c. Using Lean methodology to develop, update and revisit action plans ensures staff engagement with decision making and improvement and provides a structure for multidisciplinary input in planning and execution of strategies. QIVI Director November 2, 2015 The Governing Body and Executive Leadership Team are hosting events to increase input and engagement in the culture of safety and assist in reducing the risk of immediate danger to patients and staff. Executive leadership hosted "open communication sessions? three times during the week of November 4, 2015, involving all shifts to soiicit feedback and to provide immediate information about current emergent safety and quality issues. These forums also solicit feedback about how to improve communication hospital wide. 0 Once per month, on each shift WSH holds all-staff meetings to ensure ongoing communication. Governing Body November 12, 2015 Quality Councii analyzes sentinel and critical events Quality Council reviews all sentinei events and intensive assessments to evaiuate and adjust practice. 0 ERMO presents reviews of staff and patient assaults Director November 13, 2015 Ii Abatement Plan #4 (Version 11/20/15) FINAL Page 2 of4 (resulting in immediate outside medical attention) to Quality Councii which makes recommendations and adjustments based on the assessment of these events. Addendum #1 November 19, 2015 The QAPI approved 10/30 and disseminated to staff appears to be the same plan that had identified gaps during the quality program review that was conducted during the survey. 0 The QAPI plan goals section has been rewritten as of 11/19/15 (see attached). A3 Lean Tool target conditions: result has no identified benchmarks - The A3 documents attached represent the work that has been done so far on our first Performance improvement Project developed under the new QAPI pian. This project is not complete and the attached working documents represent input from a multidisciplinary group of staff, analysis of some root ca uses related to patient to patient assaults, and some potential ideas for countermeasures in the first three work sessions. Further work remains to be done to identify and finalize the action pian and benchmarks for this project. Review of proposed counter-measures indicated there is no identified timeframe for implementation of the individual measures. QAPI lists goals as projects. - The A3 documents attached represent the work that has been done so far on our first Performance Improvement Project developed 'under the new plan. This project is not complete and the attached working documents represent input from a multidisciplinary group of staff, analysis of some root causes related to patient to patient assaults, and some potential ideas for countermeasures in the first three work sessions. Further work remains to be done to identifyand finalize the action plan and benchmarks for this project. The QAPI plan goals section has been rewritten as of 11/19/15 (see attached). IJ Abatement Pian #4 (Version 11/20/15) FINAL Page 3 of4 Addendum November 20, 2015 We want to clarify that the removal of the immediacy for the quality is dependent upon the successful implementation of all the other improvement processes that have been developed. Your quality is the largest umbrella. What we are going to be looking for the removal of the immediacy for the quality is how well did everything else go. WSH understands that the success of a Quality Management Department and QAPI is dependent upon the successful implementation, monitoring and continuous improvement of programs and processes across the hospital. 0 WSH understands that the successful Abatement 0f the Immediate Jeopardy-related to Quality Improvement depends upon the successful abatement of the immediate jeopardies related to patient and staff safety in notices 1, 2, 3, 5 and 6. Abatement Plan #4 (Version 11/20/15) FINAL A A Page 4 of4 Western State Hospital CMS IJ Abatement Plan #6 Infection Prevention and Control 0n 11/5/2015 at 2:15 PM, Washington State Department of Health surveyors determined that a condition existed at WESTERN STATE - HOSPITAL, that posed an immediate and serious threat to patient safety. The facility failed to ensure that the hospital deveIOped and implemented an effective infection prevention and control program. Strategy/Approach Strategy Approach/Action items Lead Status/Date Due Completed WSH has an effective infection prevention and centre! program to protect patients and staff. 1a. The Infection Control Nurse established a team of nurses to review the Nursing Standards and ensure CDC Guidelines are included. 0 Chapter 5 and 6 of the Infection Control Manual was revised to include CDC Guidelines. Infection Control Nurse Manager APNE November 13, 2015 1b. Beginning 11/16/15, the Nurse educator is training ward based staff on poiicy and procedure changes. Nurse Educator November 16, 2015 1c. The nurse educator continues to train to the number one prevention method for reducing the spread of disease: effective hand washing. Nurse Educator November 13, 2015 The infection control nurses provide education to all wards where there are patients with infections or colonized A organism related to Patients with infectious disease are identified at the time of admission and prior to intra?hospital transfer to ensure that receiving wards implement necessary precautions to prevent transmission. Adn?s?on Nume lCNume h?anager APNE November 16, 2015 IJ Abatement Plan #6 (Version 11/20/2015) FINAL Page 1 of4 precautions. WSH has created a spreadsheet to document and track all infections by type and frequency, per CDC recommendation. infection November 16, 2015 Control Nurse Manager APNE The spreadsheet is used by the infection control nurse manager to ensure tracking of infection trends within the hospital, to determine if the infections were acquired in the hospital and take action to prevent transmission. Industrial Hygienist and Clinical Nurse Specialist The Hospital industriai Hygienist has trained all the Medical Nurse Consultants as trainers for the N95 Mask- 4a. Hospital Policy 25.1 was revised to ensure that all medical nurse consultants are trainers on the N95 Mask. Training to begin 11/16/15 completion by 11/19/15 Clinical Nurse Specialist 4b. An N95 mask training kit is available in the Medical Nurse Consultant of?ce. November 16, 2015 Addendum #1 November 19, 2015 Abatement plan mentioned a spreadsheet, is this a new spreadsheet or the same one reviewed during the survey that was not accurate? 0 On 11/19/15, CMS clarified that they were not referring to the spreadsheet. Instead, the daily Medical Nurse Consultant (MNC)report was found to have inaccuracies. I The content ofthe daily MNC report will now (effective 11/20/15) be verified by three sources: the microbiology report from the laboratory, the infection-control tracking report, and patient records. A The Infection Control Department, in collaboration with the MNC, will make any needed corrections to the report daily. How are we going to ensure appropriate precautions are employed when patients are on isolation? Precautions that are going to be used are not clear. Abatement Plan #6 (Version 11/20/2015) FINAL Page 2 of 4 0 All the staff on the ward providing care for the infected patient(s) are aware of what precautions are present via inter-shift and the daily Medical Nurse Consultant (MNC) report. Infection Control will work with the ward physician for an order for the appropriate precautions needed. The precautions are contingent upon the infections. We offer the following kinds of precautions: standard precautions, contact precautions, drOpIet precautions and airborne precautions per CDC recommendation. These are Eisted in our updated Infection Controi Manual (Chapters 5 6) I This information wili be disseminated to the RN35 and included in the inter-shift report to ensure that all staff are aware of which patients have infections and what precaUtions need to be implemented. Education on hand hygiene-no mention of audits and the previous approach was inadequate. 0 Education on hand washing is provided to all new employees during new employee orientation and annually thereafter. 0 All staff are to coach their peers if they observe cowworkers not using appropriate hand hygiene "see something, say something?. If staff - are uncomfortabie approaching if their peer refuses to abide by their coaching, they are to report the incident to their supervisor. Reguiar hand washing audits wili continue at least quarterly, including audits 'of the medical nurse consultants by infection control staff. . 0 Audit processes are being reviewed and updated to include an increased number of observations and additional areas such as giucoscan, wound care and medication pass. 0 Audit findings are reported to the Infection Control Department which in turn reports to the Patient Care Committee and Quality Management Department to track and trend compliance data and provide continuous quality improvement. 0 Quality Management will determine whether this issue warrants a Performance Improvement Project. a Nurse supervisors have been instructed to be more vigilant about observing and coaching hand hygiene practices during the course of their other duties in the patient care environment. Will training involve direct observation? Audits? - Nursing new employee orientation includes hand hygiene discussion and observations. Audits include direct observation. 0 Infection Control Department will observe hand washing on wards where a trending of infections has been noted. 0 Hand hygiene reminders are being posted in the physical patient care environment and added to electronic communications. Is there going to be tracking of infections that occur with change of condition as well as the parameters already identified? El Abatement Plan #6 (Version 11/20/2015) FINAL Page 3 of4 Yes, there is a tracking of infection when there is a change of condition. We use the same process that is used to track infections. Changes in condition are tracked using the MNCreport, the microbiology report and the infection control spreadsheet. Need to know who has MDROs in the facility?whether they are colonized or infected-and that information needs to be disseminated to the staff that need to know. - MDROs are identified in the microbiology report received from the WSH laboratory. Once microorganisms are identified the ward MD determines if it is an infection or colonization, determines treatment and orders necessary precautions. The precautions are listed 'in the inter?shift report to inform all patient care staff. An Interim plan for providing a consultant or a properly trained individual to support the current Infection Preventionist. WSH has been authorized to obtain a consultant. The Infection Control Nurse is working with the Association for Professionals in infection Control (APIC) for contract procurement to evaluate the effectiveness of WSH infection control program and make recommendations for improvement. Addendum November 20, 2015 We want to stress thatyou have to have an accurate communication about who is infected, who is colonized and what you are going to be doing with those patients, at a minimum you must successfully implement standard precautions and that you need to havespecific policies and procedures in place for how to proceed when someone is either colonized or infected. Accurate communication is given to staff via the inter?shift report about who is infected and who is colonized. 0 At a minimum standard precautions are implemented hospital wide and all higher level precautions (isolation, droplet, contact and airborne) are implemented based upon the physician?s order. 0 Upon receipt of a physician order, the nurse on the ward contacts the infection control department or IVINC telephonicaliy to alert them of the need to provide instruction to ward staff on implementing the precautions. When patients are infected or colonized, Infection Control Nurses or Medical Nurse Consultants visit the wards to provide training to staff about how to manage the ordered precautions. Signs that describe the various types of precautions have been posted in the break rooms, patient chart areas. Abatement Plan #6 (Version 11/20/2015) FINAL Page 4 of4