The 30 patients known to have been infected with hepatitis C by New Hampshire's Exeter Hospital may have acquired the virus because a technician was allowed to work with "weeping/discharge of fluids and blood-like stains" from his skin, and not necessarily through illegal drug diversion and syringe reuse, according to a federal complaint survey report released Thursday.
"It was revealed through interview that Staff B (Scrub technician) had 3 open lesions and a finger cut that needed stitches at times during Staff B's employment from date of hire on 4/11/11 until 5/16/12," the report says.
"On further interview with Staff A it was revealed that Staff B was asked to leave the work area several times due to weeping/discharge of fluids and blood-like stains on Staff B's scrubs [clothing] including at least once during a procedure."
Charges of drug diversion
The U.S. Attorney's office on July 19 charged former Exeter radiology technician David Matthew Kwiatkowski, 32, with obtaining controlled substances by fraud and tampering with a consumer product.
He is alleged to have taken syringes filled with fentanyl intended for use on patients in the cardiac catheterization lab, injecting himself with them, possibly filling them with another liquid and then leaving them to be used for the patients they were originally intended.
The complaint survey was conducted by the New Hampshire Bureau of Licensing and Certification on behalf of the Centers for Medicare & Medicaid Services. John Martin, the state bureau's manager, confirmed via e-mail late Thursday that the technician with weeping skin lesions referred to in the report and Kwiatkowski are the same person.
Asked if open skin lesions might have resulted in patients being infected, rather than an employee's alleged theft of fentanyl in syringes and the infection transmitted when the syringes were reused for patients, Martin replied, "It could have been either. What we were able to verify is that he was seen in the lab with open wounds. We also know that drug diversion was possible given the way they handled meds."
Medicare eligibility threatened
The CMS complaint survey resulted in "condition-level" findings, indicating that if they had not been fixed, the hospital could have become ineligible for federal reimbursement for care provided to Medicare and Medicaid patients. Such violations, however, virtually never reach that point.
The report quotes Centers for Disease Control and Prevention recommendations that "healthcare workers who have exudative lesions or weeping dermatitis should refrain from all direct care and from handling patient care equipment and devices used in performing invasive procedures until the condition resolves..."
According to the complaint survey report, the hospital's policy was to allow an employee with skin diseases, abscesses, infected acne, boils, skin lesions, impetigo, wounds, secretions, draining areas to work "if areas [sic] is adequately covered until healed."
Kwiatkowski worked at Exeter between April, 2011 and May, 2012, when he was suspended, according to the U.S. Attorney's affidavit.
The charges against Kwiatkowski have prompted 11 hospitals in eight other states where he worked in recent years to scour their records for his negative infectious disease test results. Those who cannot ascertain he was not infected at that time are trying to find patients to get them back in for testing.
Because he had been let go from two other hospitals prior to his hire by a staffing company for work at Exeter, the issue raises questions about why Kwiatkowski was never reported to the National Practitioner Data Bank, or if he was, why his behavior escaped notice by future employers.
Numerous lapses
The CMS complaint survey released Thursday catalogues a slew of other drug safety and infection control lapses at Exeter Hospital.
According to the report, the hospital had no policy for cleaning glucometers, devices used for measuring blood glucose, in between patients; some units cleaned them only after they were used in precaution rooms while one unit indicated the cleanings were done in the morning and at night.
Contact precautions also were not routinely observed by hospital staff, the report said. During the survey visit, investigators observed a staff member "in a patient's room with the contact precaution sign outside the patient's door. The staff member as wearing a lab coat and was standing next to the patient's bed and did not have any contact precaution gear on." The staff member was identified as someone from physical therapy.
Failure to provide a sanitary environment
The hospital's semi-restricted corridors have perforated ceiling tiles that are not scrubbable and capable of withstanding cleaning and/or disinfecting chemicals. This led investigators to conclude that the hospital failed to "provide a sanitary environment to avoid sources and transmission of infections and communicable diseases."
Specifically, the report says Exeter failed by not developing and, or implementing policy and procedures following recognized standards for
- "The cleaning and disinfecting of equipment between patient uses on five of seven distinct hospital areas."
- "The appropriate gowning when entering the room of a patient on infection precaution in one of seven areas."
- "The criteria for employees with potential infectious process for being able to work in direct patient care."
- "For allowing an employee with draining wounds to participate in an environment where invasive procedures were being performed."
Plan of correction approved
Martin said that the hospital's plan of correction (PoC) has been approved. The document includes a line-by-line detailed explanation from Exeter hospital officials specifying how the lapses have been or are being corrected.
"We will follow up at some point with an announced visit to verify that all of the corrective action set forth in the PoC has been implemented. I do not anticipate an enforcement action in this case," Martin said.