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Based on observation, interview, and record review, the facility failed to follow their infection prevention and control program policies for 3 (#1, #2, #7) of 7 observations, resulting in the potential for transmission of organisms to any patient in the facility. Findings include:

On 7/24/23 at approximately 1030, a visitor was observed in a "Contact Precautions" posted room 5813 without personal protective gown or gloves on. The visitor was interviewed shortly after the observation and she stated that she was the sister of patient #2, it was her second visit and she had not been instructed on the use of personal protective equipment (PPE). On 7/24/23 at approximately 1045, interview with the patient's Nurse G revealed that she had not seen or instructed the visitor. She stated that the sign for contact precautions was visible outside the door, but the visitor did not come to the desk. Review of patient #2's medical record with Nurse G, on 7/24/23 at 1050, revealed that patient #2 was in contact precautions for a history of Carbapenem-resistant Enterobacterales (CRE) bacteria, and had not had a second negative test yet.

On 7/24/23 at approximately 1105, Staff H was observed going into a "Contact Precautions" posted room 4819 without out a gown on. Interview with Staff H, on 7/24/23 at approximately 1108 revealed that she was a Respiratory Therapist and she stated that she did have gloves on and had not touched the patient. She further stated that she had gone into the room to change the alarms to match the settings on the respiratory equipment. On 7/24/23 at 1115, review of patient #7's medical record with Nurse I revealed that the patient was also in contact precautions for a history of Carbapenem-resistant Enterobacterales (CRE) bacteria.

On 7/24/23 at approximately 1130, Nurse K was observed in "Contact Precautions" posted room 4811 without a gown on. Interview with Nurse K, on 7/24/23 at 1133, revealed that she had gone in the room to silence an alarm. She stated that she had gloves on to do that and a gown was not needed because she did not come into contact with the patient. Review of patient #1's medical record with Nurse K, on 7/24/23 at 1135, revealed that the patient was in isolation for Carbapenem-resistant Enterobacterales (CRE) bacteria, multidrug resistant Acinetobacter bacteria, and multidrug resistant Pseudomonas bacterial organisms.

On 7/24/23 at approximately 1530, review of the facility policy and procedure titled "Isolation Practices, updated 4/25/23" documented, "Contact Precautions or contact isolation are designed to reduce the risk of transmission of organisms by either direct or indirect contact with patients, devices or environmental surfaces... Single-use gowns and gloves must be put on upon entering the room..." Also documented in the policy, "Guests must report to the nurse's station for instructions before entering an isolation room for the first time. Patients and guests (family and friends) should be provided with education on isolation to ensure compliance with posted precautions."

On 7/25/23 at approximately 1100, Epidemiology Manager X was queried about staff and visitors not putting on gowns when entering contact isolation rooms and she stated, "That's not appropriate."