Becker's Hospital Review

14 INFECTION CONTROL & PATIENT SAFETY CMS: 2 patient deaths resulted from failures by Kansas hospital staff By Gabrielle Masson A er CMS regulators said Overland Park, Kan.-based Pinnacle Regional Hospital put patients in "immediate jeopardy" in June 2018, the agency linked two patient deaths to several failures by hos- pital staff, according to NPR affiliate KCUR. Travis Claussen had his right hip replaced Feb. 6, 2018, at Pinnacle Regional Hospital, formerly known as Blue Valley Hospital. e 40-year-old was readmitted to the hospital aer developing a surgical site infection. On April 9, 2018, Mr. Claussen's hip implants were removed, but his femur was fractured during the procedure. He was given large quantities of narcotics, including fentanyl, during the next 24 hours and was found unresponsive by a nurse April 11, 2018. Mr. Claussen should've been transferred to another hospital with a higher level of care, Andrea Carabetta, PharmD, who was pharmacy director at the hospital until 2018, told KCUR. She said she believed he had been kept at the hospital "to keep the patient census up to meet CMS requirements." "I feel like they killed him," Dr. Carabetta said. In December 2017, 36-year-old Joseph Metz underwent spinal fusion surgery at the hospital. He was discharged despite a high temperature and pneumonia — diagnosed posthumously — and was discovered dead at his home the next day. Both patients' autopsy reports indicated fentanyl or oxycodone intoxication was a contributing factor in the deaths, the CMS report said. Narcan was not used, though Mr. Claussen's case "screamed of overdose," one staff member told CMS. In October 2019, a representative of Mr. Metz's estate sued the hospital and two of its physicians, alleging negligence. e defendants denied allegations, claiming the injuries "were the direct and unavoidable consequence of Joseph Metz's preexisting condition." Mr. Claussen's family filed a separate lawsuit Feb. 13, also alleging negligence. e hospital did not return phone calls from KCUR seeking comment. Pinnacle Regional Hospital filed for bankruptcy Feb. 12. n Toilet flushing may spread C. diff in hospital bathrooms By Mackenzie Bean C losing the toilet lid before flushing may help limit the spread of Clostridium difficile in patient rooms, suggest the findings of a study pub- lished in Infection Control & Hospital Epidemiology. For the study, researchers collected bioaerosol samples from the bathrooms of 24 patients with C. difficile infections at the University of Iowa Hospitals and Clinics in Iowa City. Samples were taken from the air near toilet rims 20 minutes before and after flushing. Of 72 samples collected before toilet flushing, 13 percent tested positive for healthcare-associated bacteria. In contrast, 26 percent of the 72 samples taken after flushing tested positive for bacteria. The most commonly detected bacteria were Enterococ- cus faecalis, Enterococcus faecium and C. difficile. "Bioaerosols produced by toilet flushing potentially contribute to hospital environmental contamination," researchers concluded. "Prevention measures (eg, toilet lids) should be evaluated as interventions to prevent toilet-associated environmental contamina- tion in clinical settings." n 77% of California hospitals haven't made safety updates after patient assault By Mackenzie Bean A hospital safety law California enacted three years ago has done little to prevent workplace violence, health- care employees told NBC Bay Area. The law, which took effect in summer 2017, requires hospitals to develop violence prevention plans and report all assaults against employees to the state. Hospitals that don't follow these requirements can be fined $25,000 for a first offense and up to $132,765 for a repeat violation. However, healthcare workers across the state told NBC Bay Area that patient assaults are still a regular occurrence at their hospitals. Nearly 23,000 assaults have been reported to California's Division of Occupational Safety and Health since the law took effect, and 77 percent of hospitals did not make safety improvements after reporting an assault. Doug Parker, chief of the OSHA division, said it's too early to say whether the law has helped improve workplace safety. "I think that there's more awareness, but I wouldn't feel com- fortable at this point saying that there's been a major impact yet. It's still a work in progress," he told NBC Bay Area. Many hospitals are struggling to comply with the law be- cause it asks them to spend more money on safety without increasing funding, a spokesperson for the California Hos- pital Association told the publication. n

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