'Last Shot' for Embattled Exeter Hospital

It may be the third and last strike for Exeter Hospital.

The 100-bed New Hampshire facility—now infamous for employing a hepatitis C–infected tech whose alleged proclivity to inject himself with syringes intended for patients resulted in his infecting some 32 people—failed to pass its third inspection in September.

A report on that survey visit indicates that many of the problems the hospital was told to correct in two earlier inspection surveys remain, including some dealing with essential infection control practices. The new report was released Wednesday by the federal Centers for Medicare & Medicaid Services and the state health department's Bureau of Licensing and Certification.

"They are still on a termination track," says John B. Martin, manager of the state bureau that helped CMS inspect the hospital. "They are out of compliance. As far as I know, this is their last shot. When we go back in to do our next follow-up inspection by the end of the year, they'll need to be in compliance."

Or else.

"I don't know what flexibility CMS has around this," Martin adds.

Kiss of Death
CMS almost never takes the egregious step of denying a hospital's ability to receive payment for Medicare and Medicaid patients, which for most facilities represents so much money that it would be the kiss of death. But a read of the latest document may explain why regulatory agencies are having such a tough time with this small rural hospital.

Even though the so-called serial infector David Kwiatkowski, who faces charges from the U.S. Attorney's Office that he obtained controlled substances by fraud and tampering with a consumer product, has been terminated from hospital employment, a lax hospital culture that allowed his behavior to occur apparently remains.

Exeter failed to have an "effective governing body." It failed to keep drugs and biologicals secure, and its staff lacked full knowledge relating to the security of its drug access system, according to the report. The hospital failed to maintain secure access to the emergency department.

Infection control is biggest issue
But it is Exeter's basic infection control issues that are the biggest remaining concern, Martin says.

In August, another survey document detailed Exeter's failure to establish policies and procedures to prevent workers with open wounds from being near patients. One employee, subsequently identified as Kwiatkowski, was on several occasions seen to be working with "open lesions."

The latest report doesn’t mention that. But it does detail that the hospital failed to set up a hospital-wide infection control program and failed to ensure that infection control practices were followed on three out of four units. Inspectors observed personnel not following infectious disease protocols.

For example, according to the latest report, investigators observed a staff member who was gowned and gloved while cleaning a room. But after cleaning the room, the staff member removed the gown but kept the gloves on outside the room.

"Staff was observed placing their hands, which were still gloved after cleaning the contact precaution room, on the handrail outside the room. The same staff person then returned inside the room and removed the garbage bag from the receptacle and tied off the bag," the report says.

"The staff person was then observed walking out of the room, around the nurse's station, and down the hall to the dirty utility room. During this time the staff person was observed to drag the garbage bag on the floor and use their still-gloved hand to open the door handle on the dirty utility room to enter."

Key members of the infection control staff apparently did not know who provided infection control training to housekeeping staff.

Another example involved investigators' questioning of a member of Exeter's housekeeping staff as to what product should be used to clean a room previously occupied by a patient with C-difficile. "The housekeeper identified a product called 'Virex 256.' This product was later identified by the director of housekeeping to not be effective against this bacterium."

Virex 256 fights viruses. C-difficile is a bacterium.

Exeter hospital officials wrote in tremendous detail, as they did in the August report, how they plan to correct all of their deficiencies from the governing body down to the housekeeping staff. CMS and state officials will need to revisit to make sure they carry out their promises, to be sure.

Poor root cause analysis
One shortcoming stands out above the others: how the hospital was performing its root cause analysis of the Kwiatkowski incident.

"The analysis did not contain the necessary scope to address all causal factors," the report says. "Although the analysis looked at infection control and medication security, it did so with a very narrow focus. Based on the findings, a much wider scope for both was necessary to establish a true root cause, providing the ability to analyze and evaluate the quality of their existing programs pertaining to infection control and medication security."

"During tour of the cardiac catheterization procedure room on 9/17/12 at 11:50 a.m.," the report continues, "medications were found in an unlocked refrigerator" and a member of the cath lab staff "confirmed that medications were not locked even during off hours." And the hospital had still, during the September federal inspection, not figured out how to secure medications in the cath lab, to which Kwiatkowski allegedly had unauthorized access before his termination.

You'd think after three tries, Exeter would get this thing right, so it might live past its dubious distinction as the home of the "serial infector."

As Martin warns, this is their last shot.