Date: 19 th March 2015 Review: 30 th April 2015

Transcription

1 Quality Improvement Plans based on the Unannounced Hygiene Audit Report By the Health Information and Quality Authority (HIQA) at UL Hospitals, Nenagh Hospital on the 21 st October 2014 (existing hospital QIP based on unannounced HIQA visit in September 2013 amalgamated) Developed and updated by: Ms., Operational Director of Nursing, U.L. Hospitals, Nenagh Hospital Ms. Bridget Kelly, CNM2, U.L. Hospitals, Nenagh Hospital Ms. Louise Ryan, IP&C Clinical Nurse Specialist, U.L. Hospitals, Nenagh Hospital Ms. Cathrina Ryan, ADON Perioperative, UL Hospitals, Nenagh Hospital Ms. Noreen Hough, ADON Medicine, UL Hospitals, Nenagh Hospital Mr. Alan O Gorman, ADON IP&C, U.L. Hospitals Ms. Theresa Fallon, ADON Hygiene Services, UL Hospitals. Ms. Brenda Slattery, Hygiene Services Staff Nurse, UL Hospitals Mr. Phillip Brennan,, U.L. Hospitals, Nenagh Hospital Ms., Director of, U.L. Hospitals Date: 19 th March 2015 Review:

2 Standard 4 Human Resource Deficits in Hygiene staff WTE identified on Medical 2 ward Recruit and replace deficits in hygiene WTE Unacceptable levels of dust observed on the undercarriages of beds and bed rails Deep Clean of both Medical wards Placed on Hospital risk register in April 2014 and escalated to Risk resubmitted to newly appointed Chief Operations Officer Noreen Spillane 09 th Extra hours allocated for initial Deep Clean of both Medical wards Josephine Hynes HR Noreen Spillane COO Interviews for additional MTA s have taken place for the UHL Group November 2014 recruitment and training across ULH Group. Awaiting allocation to Nenagh Monitor and update when new staff allocated Unacceptable levels of dust on ledges and skirting boards in patient bed space. Re-instate Vacuum cleaning of patient bed spaces New work route / plan devised. Awaiting implementation via HR route Josephine Hynes HR Awaiting allocation and training of new staff Unacceptable level of dust and dirt on floor and edges Implement deep clean rota of rooms where all furniture and beds are pulled out, cleaned returned to room e.g. Room every Monday. 2+3 every Tuesday. Weekly / Deep clean schedule devised. Awaiting implementation of same via HR route Josephine Hynes HR High Dust Levels and non compliance with National Hospital Cleaning Standards due to staff defecits registered on the Risk Register hygiene hygiene audits.

3 Unacceptable levels of dust on patients locker Deep Clean of both Medical wards Extra hours allocated for initial Deep Clean of both Medical wards Implement deep clean rota of rooms where all furniture and beds are pulled out, cleaned, returned to room e.g. Room every Monday. 3+4 every Tuesday. Weekly / Deep clean schedule devised. Awaiting implementation of same via HR route Josephine Hynes HR Awaiting allocation and training of new staff High Dust Levels and non compliance with National Hospital Cleaning Standards due to staff defecits registered on the Risk Register hygiene hygiene audits. Unacceptable levels of high dust on curtain rails Deep Clean of both Medical wards Implement deep clean rota of rooms where all furniture and beds are pulled out, cleaned returned to room e.g. Room every Monday. 3+4 every Tuesday. Extra hours allocated for initial Deep Clean of both Medical wards Weekly / Deep clean schedule devised. Awaiting implementation of same via HR route Josephine Hynes HR Awaiting allocation and training of new staff High Dust Levels and non compliance with National Hospital Cleaning Standards due to staff defecits entered on the Risk Register hygiene hygiene audits

4 Mattress cover compromised and soiled Immediate removal of damaged mattress. Mattress removed and replaced October 2014 integrity of mattresses and replace as required. Re-audit of mattresses hospital wide to be carried out 1 st quarter 2015 Staff re-educated to observe mattress integrity when bed making Incorporated into monthly Hygiene Audits Monitor bed occupancy and carry out audit when occupancy permits Brenda Slattery S/N Hygiene October 2014 Audit and replacement commenced. Business plan submitted to ULH Group Medical Directorate seeking funding to replace damaged mattresses. Peeling paint, staining and damage to wall Maintenance review of all patient areas to compile maintenance schedule of works Phased repair and repainting of walls Phillip Brennan Rolling replacement / decontamination being organised for rental air mattresses Worked commenced with plastering / painting repair. monitoring and repair Peeling paint in patient shower room hygiene hygiene audits Radiator Grill and piping dusty Rust also noted Clean all radiators Hospital wide. Schedule to be implemented by maintenance DON/ADON Office Phillip Brennan March 2015 Top Floor Radiators Deep Cleaned Radiators Painted

5 department for management of radiators with ADON office and Deep Cleaned. Schedule repeat Deep clean September 2015 September 2015 Rust to be attended to by maintenance hygiene hygiene audits Flooring Bubbling, marked and worn Repair or Replace Maintenance Review of flooring in wards of work that needs to be completed or repaired Phillip Brennan March 2015 Repaired hygiene hygiene audits Rust Colour staining on wheel of iv stand with paint missing Remove all with rust Directive to be issued to Ward CNMs for review of and removal of rusty patient patient audits Light dust noted on the base of the Daily Check of Resuscitation trolley Resuscitation trolley being cleaned daily by

6 resuscitation trolley to include cleaning. nursing staff member checking patient patient audits Sanitary not being checked in the evening checklists not being signed off in evening Sanitary check sheet to be redesigned to reflect National Cleaning standard of 3 cleans and 2 check cleans a day. Planned redesign of shift pattern to have availability of Hygiene attendants on duty in afternoons / evenings to carry out checks / cleans Interviews for additional MTA s have taken place for the UHL Group November 2014 Deficits in Hygiene WTE identified Placed on Hospital risk register in April 2014 and escalated to Resubmitted to newly appointed Chief Operations Officer Noreen Spillane 09 th Noreen Spillane COO Awaiting allocation and training of new staff Non compliance with National Hospital Cleaning Standards and HIQA Standards due to staff defecits entered on the Risk Register Waste bins not clean across ward patients sanitary facilities Immediate Deep clean of bins sanitary facility audits Immediate deep clean of bins undertaken All bins to be cleaned inside and out as they Review of the allocated duties being Awaiting agreement of duty allocation

7 are emptied. undertaken with HR / hygiene hygiene audits Entered on risk register due to IP&C risk ABG Machine had ADON Office November 2014 spots of blood on it. Not cleaned after use ABG Machine to have recorded clean once a day when daily check being carried out. ABG Machine returned to the Lab. Cleaned every morning with daily check Unacceptable level of dust and sticky residue on cardiac monitor. Temperature probe dirty Inconsistent tagging of patient Circular from IP&C re compliance with cleaning of ABG Machine after each use to be forwarded to all staff members including Medical Consultants Re-iterate to all staff the need for cleaning of patient pre/post use. Implement once day clean of patient and tagging by MTA Sent Easy accessible detergent wipes clipped on to portable monitors Patient cleaning log book devised. Awaiting implementation of same and allocation of duty via HR route IP&C Laminated Notice beside ABG Machine reminding to clean after use and instructions on how to do so. ABG Machine appropriate wipes available beside machine Patient Log devised. Patient labelling tags sourced. Awaiting agreement of duty allocation

8 patient patient audits Sharps trays not clean with debris left in them All trays to be decontaminated after each use. DON/ADON Office IPC safe management of sharps education arranged for February 2015 Staff re-educated re the need for decontamination of patient after use and the associated risk of BBVs February 2015 Targeted Education / monitoring of NCHD S Follow-up sharps audit will be carried out following staff education Feb/March 2015 External Education and Audit undertaken by Patron Circular from IP&C re compliance with cleaning of sharps trays after each use to be forwarded to all staff members including Medical Consultants sent sent patient patient audits Commodes stained and dirty in Sluice room Re-iterate to all staff the need for cleaning of patient November 2015 Staff being reminded at report time

9 pre/post use. Advise re the risk of transmission of HCAI e.g. C difficile infection Education sessions on prevention of HCAIs & decontamination of patient scheduled for Feb 2015 February 2015 IP&C CNS.4 WTE allocation to Nenagh. Same active on Risk register Implement once day clean of patient by MTA Once a day deep clean and tagging in place. CLOSED patient patient audits Once Day Deep clean being carried out first thing in morning by MTA. Tagging across seat to verify same Patient monitoring not cleaned between each patient Education of nursing staff on the need for decontamination of patient pre/post use. patient Easy accessible detergent wipes clipped on to portable monitors Education sessions on prevention of HCAIs & decontamination of patient scheduled for Feb 2015 patient audits February 2015 Daily Education Sessions at Report time IP&C CNS.4 WTE allocation to Nenagh. Same active on Risk register and Sticky residue and dust noted in metal presses in sluice Immediate deep clean of presses Hygiene Attendant to be reminded that the presses are to be done DON/ADON Office Deep Clean of both Medical wards carried out

10 when cleaning sluice wards Sanitary sanitary facility audits Bedpan / Urinals stored incorrectly not inverted Need to acquire and install correct Bedpan racks Being Actioned Phillip Brennan May 2015 Being Actioned Defecits in staff WTE in active on Risk Register. Escalated to Corporate risk register in 2014 May 2015 wards Sanitary sanitary facility audits Daily Education Staff Education / and sessions at report time reminder at report time daily Patient not clean ECG Machines, patients monitors, patients hoist, suction, infusion pumps, ng feeding pump Education of nursing staff the need for cleaning of patient pre/post use. Education of nursing staff re transmission of HCAI Education sessions on prevention of HCAIs scheduled for Feb 2015 February 2015 IP&C CNS.4 WTE allocation to Nenagh. Same active on Risk register 30 TH April 2015 Implement once day clean of patient by MTA with tagging Hygiene WTE deficit identified and placed on Hospital risk register August 2014 Escalated to Corporate risk register September 2014 March 2015 Patient Log devised. Patient labelling tags sourced. Awaiting agreement of duty allocation via HR Resubmitted to newly appointed COO Noreen Spillane Non Compliance with National Hospital Cleaning standards and non compliance with

11 HIQA Hygiene Recommendations entered onto Risk Register The design of some clinical hand wash sinks do not conform to Health Building note Part C: Sanitary Assemblies patient Hospital wide review to be carried out to assess non-compliance of clinical WHBs Report findings to Regional Monitoring Committee and seek recommendations patient audits Put on Agenda for discussion at next meeting February 2015 Phillip Brennan February 2015 Issue addressed at the EMC. Not deemed a high risk priority at present. To be revisited Suspended wards Hand Hygiene Hand hygiene facilities audits Standard 6 Hand Hygiene To be installed IP&C Alcohol hand gel not available at every patient bed Alcohol hand gel available at every point of care wards Hand Hygiene Hand hygiene facilities audits Standard 6 Hand Hygiene Hand hygiene not performed before touching a patient - Moment 1 (3 opportunities) Hand hygiene not performed after touching a patient Review of hand hygiene education attendance at Dept level. Target 100% in date hand hygiene education for all staff Hand hygiene train the trainers to assist with hand hygiene Additional hand hygiene education provided with Noreen Hough, November 2014 training Hand hygiene education provided for Medical 2 staff at ward level - March 2015

12 Moment 4 (2 opportunities) Hand hygiene not performed after touching one patient and prior to touching the next patient ( 1 opportunity) Hand Hygiene not performed after touching a patients surroundings Moment 5 ( 1 opportunity) 7 hand hygiene actions lasted less than 15secs (against recommendations) education at dept level Increased auditing with Hospital of hand hygiene - joint auditing Non Compliances with HSE Hand Hygiene Policy will be reported and followed up Hand Hygiene Standards increased focus on hand hygiene for Feb 15 2 Hand hygiene train the trainers education completed December 2014 Quarterly Hand Hygiene Audits by IP&C ADON Medical Directorate IP&C and ADON Office ADON Office Quarterly & November 2014 Auditing and Education. Train the trainers Education completed IP&C CNS.4 WTE allocation to Nenagh. Same active on Risk register Main reception unclean floors unclean and scuffed Immediate clean Immediate clean DON/ ADON Office October 2014 To be included in daily work rota All public areas to included in work rota Being tended to daily monitoring Hygiene Standards Hygiene Audits ADON Office Glass on entrance door not clean Windows to be cleaned inside and outside Noonan Contractors to clean windows Brenda Slattery S/N Hygiene Phillip Brennan Maintenance December th November 14

13 Hygiene Standards Hygiene Audits ADON Office Boxes stacked inside the main entrance door Boxes not to be left in reception Boxes removed. Not to be used as storage area MTA Stores November 2014 monitoring monitoring Hygiene Standards Hygiene Audits ADON Office Hand hygiene posters noted but not in prominent position at hospital entrance Place hand hygiene poster in prominent position at reception Re-activate talking signs reminding the public & staff to perform hand hygiene Review available hand hygiene posters CNS Philip Brennan, February 2015 Promotional poster being sourced and quotations being sought In House talking signs broken. New signs to be procured Hand Hygiene promotion facilities Hand Hygiene Audits ADON Office

14 Outstanding QIP from unannounced visit 2013 Findings/ Non Compliance Action Plans Action Taken Lead Responsibility Target Timeframe Progress To Date Review Adhesive tape residue found on heads of beds, white trunking panels. Medical 1 Ward/Medical 2 Ward Implement deep clean rota of rooms where all furniture and beds are pulled out, cleaned returned to room e.g. Room every Monday. 3+4 every Tuesday. Redesign cleaning schedules and records Work in Progress DON/ADON OFFICE WARD CNM2 ONGOING Deep Clean Carried Out. See Existing QIP CLOSED Hygiene Standards Hygiene Audits Sticky residue noted on patient bed lockers Dust under mattresses at edge of metal bases. Implement deep clean rota of rooms where all furniture and beds are pulled out, cleaned returned to room e.g. Room every Monday. 3+4 every Tuesday. Redesign cleaning schedules and records Work in Progress DON/ADON OFFICE WARD CNM2 ONGOING Deep Clean Carried Out. See Existing QIP CLOSED Hygiene Standards Hygiene Audits Dust and grime in the corners of floors in patient areas. Dust noted on light Vacuuming to be implemented in patient bed spaces prior to washing Redesign cleaning schedules and records Work in Progress DON/ADON OFFICE WARD CNM2 ONGOING High Dust Levels and non compliance with National CLOSED SEE EXISTING QIP

15 fittings and curtain rails. Medical 1 Ward /Medical 2 Ward Hygiene Standards Hygiene Audits Hospital Cleaning Standards due to staff defecits registered on the Risk Register Quality improvement plans developed in response to findings of departmental audits do not designate a responsible person or time frame for completion Ward CNM2 to take ownership of ward QIPS Audits and QIPS Being given to cnm2 by auditors Ward CNM2 Relevant ADON ONGOING IN PROGRESS monitoring Inappropriate storage of chemicals in dirty utility -Medical 1 Inappropriate storage of chemicals Clean utility-medical 2 Secure Chemical press to be installed in cleaning storage room Being Actioned Phillip Brennan March 2015 In Progress Defecits in staff WTE in active on Risk Register. Escalated to Corporate risk register in 2014 MAY 2015