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Based on review of Airborne Isolation Room logs and interview, it was determined the facility failed to assure, as part of the Infection Control Program, a policy and procedure was in place to require daily visual checks to assure negative pressure was maintained when the Airborne Isolation Rooms were occupied by patients who required airborne isolation. There were two patients identified by the Infection Control Nurse who required airborne isolation from 02/2009- 02/2010. Three of three Airborne Isolation rooms occupied by the two patients were not checked daily to assure negative pressure was maintained. The failed practice had the potential to affect all patients hospitalized on the affected Units.

A. In an interview with Director #1 on 03/08/10 at 1255, she stated the Facilities Department was responsible for checking the Airborne Isolation Rooms for negative pressure and each room has audible negative pressure failure alarms that sound on the Unit. A copy of the facility policy for Airborne Isolation rooms was provided by the Infection Control Nurse on 03/08/10 at 1330, "Respiratory Isolation-TB" Section 510.1 stated "Patients requiring respiratory isolation for TB (tuberculosis) will be placed in rooms (2CE) 2201, 2202, 2203, 2204 or in SICU 2334. Once the patient is placed on respiratory (AFB) isolation, a work order will be placed to Facilities to smoke test the room daily. When isolation is discontinued, another work order will be placed to discontinue the smoke test." The effective date for this policy was 12/29/06, last reviewed/revised 12/08.

B. In an interview with the Infection Control Nurse on 03/08/10 at 1330, she stated the facility had two patients who required TB Airborne isolation from 03/08/09 - 03/08/10. The facility Airborne Isolation Room log was reviewed on 03/08/10 at 1435 and revealed the following: Patient #1 occupied Airborne Isolation room 2334 from 09/09/09 - 09/22/09. Documentation indicated smoke test was performed on 09/10/09. Patient #1 was transferred to Airborne Isolation room 2201 and occupied that room 09/23/09 - 09/30/09. Documentation indicated a smoke test was performed on 09/23/09. Patient #2
Occupied Airborne Isolation room 2202 from 11/16/09-12/02/09. Documentation indicated a pressure check was performed on 11/17/09. The Facilities Department provided a copy of a facility policy (no title or number), effective date 03/31/08, that stated "The Facilities Department requires no daily testing procedure if the negative air alarm system is functioning properly. "

C. The Center for Disease Control "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005" contained the statement "Periodic checks are required to maintain the desired negative pressure and the optimal operation of monitoring devices. AII rooms should be checked for negative pressure before occupancy. When occupied by a patient, an AII room should be checked daily with smoke tubes or other visual checks for negative pressure. If pressure-sensing devices are used in AII rooms occupied by patients with suspected or confirmed TB disease, negative pressure should be checked daily by using smoke tubes or other visual checks."

D. The Infection Control Nurse stated on 03/08/10 at 1440 that the facility "followed the CDC (Center for Disease Control) Guidelines for Preventing the Transmission of TB and daily visual smoke checks were required when a patient was occupying the room for TB. I am not aware of any policy or procedure changes."