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Based on observation, interview, review of infection control documentation and policy review, it was determined the hospital failed to ensure the infection control officer fully developed and implemented policies and procedures for the prevention and control of infections for patients on contact precautions.


1. Review of the policy titled, "Isolation Guidelines," revised 03/2008 included the following guidelines for contact precautions, "handwashing," and "gown when in close contact with patient." Policy requirements for contact precautions included, "Wear gloves when entering the room...Wash hands with an antiseptic agent immediately before leaving the patient's room...Wear a gown if you anticipate that your clothes will have substantial contact with the patient, environmental surfaces or items in the patient's room."

The policy also included directions for posting a sign on the door of patients who were on contact precautions as follows, "...The sign posted on the patient's door will...list the necessary precautions to be taken by anyone entering the room."

2. An interview was conducted with Nurse C on 06/21/2012 at 1150. He/she stated that Patient #1 was on contact isolation precautions for colonized MRSA.

3. A tour of the MSWC was conducted with Nurse C on 06/21/2012 at 1150. During the tour, a sign was observed on the door at the hallway entrance to Patient #1's room. The sign included the following contact precautions, "Wear Gloves When Entering Room...Remove Gloves Before Leaving Patient Room...Wear Gown When Entering Patient Room...Wash Hands With Antibacterial Agent After Glove Removal..."

On 06/21/2012 at 1155, CNA M donned (put on) gloves and entered Patient #1's room. The patient was in the bed. The CNA checked the patient's CBG level while standing at the patient's bedside. He/she did not don a gown when entering the room in accordance with the posted contact precautions, when contact of his/her clothing with the patient, environmental surfaces or items in the room were likely, or "when in close contact" with the patient per hospital policy. These observations were conducted with Nurse C.

On 06/21/2012 at 1200, Physician O entered Patient #1's room. He/she did not don a gown or gloves upon entering the room. The patient was in the bed. The patient's privacy curtain was located in the patient's immediate environment. The physician was standing at the foot of the patient's bed and touched the privacy curtain with ungloved hands 2-3 times. The physician then exited the room without performing hand hygiene and took 2-3 steps into the hallway. Nurse C then asked the physician if he/she would perform hand hygiene. The physician then went back into the patient's room, performed hand hygiene, and then exited the room again. The physician did not don a gown or gloves when entering the room, or perform hand hygiene before leaving the room in accordance with the posted contact precautions and hospital policy. These observations were conducted with Nurse C.

On 06/21/2012 at 1230, Nurse N donned gloves and entered Patient #1's room. The patient was in the bed. The nurse administered an insulin injection to the patient while standing at the patient's bedside. The nurse also used the computer in the room. The nurse did not don a gown when entering the room in accordance with the posted contact precautions, when contact of his/her clothing with the patient, environmental surfaces or items in the room were likely, or "when in close contact" with the patient per hospital policy. These observations were conducted with Nurse C.

4. An interview was conducted with Nurse C on 06/21/2012 at 1240. He/she stated the hospital policy for gown use during contact precautions was that staff were required to wear a gown in the patient's room if their body or clothes had the potential to touch the patient.