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Based on observation, staff interview, and record review it was determined that 1 of 2 sampled respiratory therapists, (Staff member A), failed to adhere to Contact Isolation policy and procedures by failing to utilize personal protective equipment while assessing a patient's lung sounds in the Medical Services Unit (MSU).

The finding include:

On 10/26/21, at approximately 2:20 PM, staff member A, a respiratory therapist, was observed entering in a patient room in the Medical Services Unit (MSU). Outside the patient's room was an isolation cart with personal protective equipment (PPE), a disposable stethoscope, and a sign affixed above the cart indicating the patient was under contact isolation. The contact isolation sign instructed staff to ensure the use of masks, gloves, gowns and utilization of dedicated patient equipment.

The respiratory therapist was observed not wearing a protective gown and proceeded to auscultate (listen to) the patient's lung sounds using his personal stethoscope. The therapist did not use the disposable stethoscope.

An interview was conducted with the respiratory therapist at this time and he indicated he thought the contact isolation had been discontinued but would check with nursing staff. The respiratory therapist was observed asking staff at the nurse's station about the contact isolation and the nurses relayed there were no orders to discontinue the contact isolation for methicillin resistant staphylococcus aureus (MRSA) wound infections. The respiratory therapist indicated he should have checked prior to entering the room.

A review of the Contact Isolation policy and procedure dated 7/1/21, revealed that isolation was designed to reduce the risk of transmission of epidemiologically important microorganisms by direct or indirect contact. Direct contact transmission involves skin to skin contact and physical transfer of microorganisms to a susceptible host from an infected or colonized person. The policy outlines the need for use of PPE as observed on the Contact Isolation signage outside the patient's room.