HospitalInspections.org

Based on policy and procedure review, hospital document review, open medical record review, direct observation, and staff interviews, the nursing staff failed to supervise and evaluate care by failing to ensure appropriate isolation precautions were in place for 1 of 1 ESBL (Extended-spectrum beta-lactamases, causes resistance to many antibiotics) patients observed (# 7).
Review of policy titled "Isolation Precautions", revised date 05/21/2015, revealed "...It is the policy of (hospital name) to institute control measures to help prevent transmission of communicable diseases....Levels of Isolation Precautions....Contact Precautions Use Contact precautions, in addition to Standard Precautions, for specified patients known or suspected to be infected or colonized with epidemiologically [looks at patterns, causes, effects of diseases] important microorganisms [organisms too small to be viewed, such as bacteria] that can be transmitted by direct contact with the patient (hand to skin-to-skin contact that occurs when performing patient care activities that require touching the patient's dry skin) or indirect contact (touching) with environmental surfaces or patient care items in the patient's environment. Consult the CDC's list of pathogens requiring isolation for more information. 1. Initiation of Patient Isolation Patients who are known or suspected to be infected with microorganisms transmitted by contact should be promptly placed on Contact Precautions and Infection Prevention should be consulted for patient flagging in [computer system]. Please note that an automatic Contact isolation flag in [computer system] will not be generated until specific tests are ordered and/or resulted positive for one of the pathogens requiring isolation. ..."
Review of a document provided by hospital staff on 09/30/2015 as the CDC document referenced in the policy revealed "...TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS....Multidrug-resistant organisms (MDROs), infection or colonization....ESBLs....Contact Precautions recommended in....acute care settings with increased risk for transmission or wounds that cannot be contained by dressings. ..."
Open Medical Record review on 09/30/2015 revealed Pt # 7 was admitted 09/23/2015 with a diagnosis of chronic EC (enterocutaneous) fistula (abnormal connection between the intestine and skin which may cause leaking of intestinal or stomach contents) and underwent surgery that included "take down" (closure) of EC fistula and ventral hernia repair. Record review revealed on 09/09/2014 Pt # 7 had a positive laboratory result for ESBL. On 09/23/2015 at 0632, record review revealed, "Contact" isolation was added. Record review revealed Pt # 7 tested negative for MRSA (Methicillin-resistant Staphylococcus aureus, bacteria that causes infection) on 09/26/2015. Further record review revealed contact isolation precautions were documented every hour on 09/29/2015.
Observation during tour of a General Surgery Unit on 09/29/2015 at 1420 revealed a patient (Pt # 7) room identified by the Charge Nurse (RN # 3) as on Contact precautions for ESBL. Observation revealed there was no Contact Isolation sign on the door of Pt # 7's room. Observation revealed a sign was then obtained and placed on the door.
Interview with Registered Nurse (RN) # 1 while on tour on 09/29/2015 at 1420 revealed RN # 1 was the nurse assigned to care for Pt # 7. Interview revealed Pt # 7 had not been on contact isolation precautions during the shift and RN # 1 had worn gloves but had not worn gowns when in the patient's room providing care. Interview revealed RN # 1 thought Pt # 7 had MRSA and the hospital no longer placed MRSA patients on contact isolation. RN # 1 reviewed Pt # 7's medical record during the interview. Record review and interview revealed Pt # 7 had ESBL, not MRSA, and should be on contact isolation. Interview revealed with contact precautions a sign designating the precautions should be on the patient room door and PPE (personal protective equipment), including gowns, should be worn when in the patient's room. Interview revealed nursing does a bedside report at change of shift and there was not a sign on the door when RN # 1 first went to the room that morning. A bedside report was done at the beginning of the shift, interview revealed, and neither the off-going RN nor RN # 1 wore gowns for contact precautions while in Pt # 7's room for report.
Interview with Employee # 2 while on tour on 09/29/2015 at 1420 revealed ESBL patients should be on contact precautions. Interview revealed there had been "some transition with wearing PPE for ESBL" and policy was not followed.
Interview with RN # 3 while on tour 9/29/2015 at 1420 revealed policy was not followed, Pt # 7 should have been on contact precautions.
NC00109316