Surviving and Thriving Immediate Jeopardy in Infection Control from the Centers for Medicare and Medicaid
Authors: Cutler Constance J 
Published: November 2020

Background: Because of a patient death from a blood transfusion, a large hospital in Houston, Texas, underwent one of the largest unannounced CMS surveys in 2019. Methods: A 520-bed quaternary-care hospital was surveyed in one of the nation’s largest CMS surveys in March 2019, with a resurvey in June 2019. In an anticipated but unannounced arrival, ∼30 CMS surveyors evaluated the hospital and 10 Clinical Laboratory Improvement Amendments surveyors looked at the laboratory. They stayed for 11 consecutive days in March. On day 4, they declared that the hospital was in immediate jeopardy in infection control for the same observations noted by several surveyors. In addition, 11 CMS surveyors returned for a shorter resurvey in June. Results: The following 14 issues were listed under the infection control heading during the first survey, which led to the immediate jeopardy designation. The hospital’s infection prevention department committed to putting remediation processes, procedures, and audits in place during the first survey, which led to lifting the IJ before the surveyors left. The following shortcomings were recorded:

(1)

Inappropriate donning and doffing of personal protective equipment (PPE) for patients in isolation

Standardized donning and doffing processes of PPE developed to include train-the-trainer and return demonstrations from >4,000 employees and providers followed by a minimum of fifty (50) audits/week with the goal of achieving 100% proper PPE donning and doffing for a minimum of three months, followed by a minimum of fifty (50) quarterly observations.

(2)

Environment Service (EVS) cleaning issues in isolation rooms

Two-person isolation room cleaning process developed, implemented, and audited a minimum of ten (10) times/week.

(3)

Incorrect set-up of dialysis machines

Minimum of five (5) dialysis machine set-ups audited/week.

(4)

Biohazard trash left in dialysis room between patients

Minimum random audits twice/week to look for biohazard trash.

(5)

Need for maintenance and cleanliness in the operating rooms (OR)

Minimum three times/week audits of rotating ORs in all locations.

(6)

Rust noted on OR equipment

Minimum of twice/week audits looking for rust on OR equipment.

(7)

Insects noted in OR

Observations for living insects will be audited twice/week.

(8)

Improper cleaning and high-level disinfection (HLD) of transvaginal probes

Minimum of three times/week, cleaning and HLD processes of probes will be observed.

(9)

Matching patient to probes in their medical records needed clarification

Minimum of twice/week, logs will be audited to check that appropriate patient/probe linkage occurs.

(10)

Contaminated gloves used on a blood bag in ambulatory setting

Once/month, removal of blood bag from transport container will be observed to observe clean/dirty glove use

(11)

Lack of cleaning between patients of durable medical equipment

Cleaning of DME will be observed for thoroughness a minimum of three times/week.

(12)

Sanitation and mislabeling issues in the kitchen

A minimum of one (1) complete audit and two (2) abbreviated audits of kitchen sanitation and food labeling will be conducted per week.

(13)

Endoscopy misuse of test strips

Test strip audits showing appropriate labeling and use will be auditing a minimum of twice/week.

(14)

Process of air blowing of automatic endoscopic reprocessor (AER) needed improvement.

Funding: None

Disclosures: None