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A. Based on interview and record review, the provider failed to control the transmission of Methicillin Resistant Staphylococcus Aureus (MRSA) in two of two sampled patient (4 and 5). Findings include:

1. Review of patient 4's medical record revealed:
*She was admitted on 5/22/10 with a diagnosis of abdominal pain, nausea, bloating, and ascites.
*An operative report dated 5/24/10 indicated the physician planned a diagnostic laparoscopy but converted to an open laparoscopy during the surgical procedure.
*The discharge summary dictated on 6/3/10 indicated the patient was stable on discharge.

Interview on 9/2/11 at 10:30 a.m. with registered nurse (RN) C revealed the patient did not have signs and symptoms of an infection during that hospital stay.

Interview and review of patient 4's medical record with RN C revealed:
*On 6/18/10 a new Port-A-Cath was placed during a surgical procedure for chemotherapy. On 6/28/10 the Port-A-Cath was infected and removed during a subsequent surgical procedure.
*A microbiology report dated 6/28/10 indicated the final result of the left chest Port-A-Cath culture was MRSA.

Interview on 9/1/11 at 11:40 a.m. with the infection control specialist revealed:
*Patient 4's Port-A-Cath infection was classified as a hospital acquired infection (HAI).
*The patient did not have MRSA upon admission. Because there was a hospital surgical procedure that fit the timeline for surgical site infections (SSI) the patient was classified as acquiring a HAI.
*A review of the infection control log revealed several patients had SSI in the following months:
*May 2010 - Two patients with SSI culture results returned positive for MRSA.
*June 2010 - Two patients with SSI culture results returned positive for MRSA.

2. Review of patient 5's medical record revealed she had a surgical procedure on 5/17/10. On 6/15/10 she was cultured positive for MRSA during a follow-up visit.

Interview on 9/1/11 at 11:40 a.m. with the infection control specialist revealed:
*Patient 5's infection was classified an SSI that was hospital acquired.
*There was no documentation from infection control discussing the above listed MRSA cases. The cases had been discussed by infection control, unit managers were provided infection control information, and it was up to them to follow through with corrective action.
*She was not sure why the spike in MRSA occurred in May 2010 and June 2010. There was no report documented.
*Staff had been reminded and encouraged to do good hand hygiene.
*Annually the staff were required to complete a computer program for infection control training.
*Patients received education on infection when in isolation.
*SSI for hernia repairs, abdominal hysterectomies, cesarean section, total hip arthroplasty, and total knee arthroplasty had been monitored for the past two years. They had observed a trend of infections for those areas. Currently hernia repair procedures and hip procedure monitoring data were not good. Operating room staff had taken steps to reduce the number of infections seen in those areas.

B. Based on observation, interview, record review, and policy review, the provider failed to ensure staff followed infection control protocols to prevent the spread of infections while performing patient care for four of four sampled patients (1, 2, 3, and 6). Findings include:

1. Observation on 9/2/11 of patient 1's dressing change revealed:
*The patient was on contact isolation.
*Registered nurse (RN) A:
-Gathered clean supplies and placed the supplies directly on the patient's bed.
-Adjusted the bed covers with her gloved hands.
-Irrigated the abdominal wound and wiped the wound with a gauze dressing.
-Without removing the contaminated gloves placed a clean dressing on the wound and secured it with tape.
-Removed her gloves, used hand sanitizer, and put on clean gloves.
-Picked up the tray of contaminated supplies and immediately replaced the tray on the bed.
-Discarded the used supplies in the trash and removed her contaminated gloves.
-Tied the trash bag closed, washed her hands, and put on clean gloves.
-Administered the patient's morning medications.
-Removed her gown and gloves, and while talking with the patient she leaned on the siderails with her hands.
-Exited the room and took the trash to the soiled utility room.
-Without washing her contaminated hands she removed linen from the linen cart, placed that linen on a table next to the Pyxis machine, removed medication from the Pyxis machine, placed those items on the isolation cart while putting on personal protective equipment (PPE), entered the patient's isolation room, and hung the intravenous medication she had removed from the Pyxis machine.

2. Observation on 9/2/11 at 9:20 a.m. revealed RN B:
*While wearing an isolation gown entered patient 2's isolation room.
*Came out of the isolation room wearing the isolation gown and walked down the hallway to the linen cart.
*Removed linen from the linen cart and reentered patient 2's isolation room.

Observation on 9/2/11 at 9:30 a.m. of RN B revealed:
*She put on an isolation gown outside of patient 2's room, did not enter the room, entered another patient's room across the hall, exited that patient's room, and then entered patient 2's isolation room.
*Patient 2 was on contact isolation.

Interview with the unit supervisor confirmed RN B should have changed her isolation gown prior to entering patient 2's room. There was a potential for cross-contamination.

3. Observation on 9/2/11 at 9:45 a.m. of patient 3's dressing change completed by RN A revealed:
*She gathered clean dressing supplies and placed them on the overbed table.
*She assisted the patient back to bed by lifting the patient's feet onto the bed, lowered the head of the bed, and raised the siderails on the bed.
*Without performing hand hygiene she put on a pair of clean gloves, touched the patient's abdomen, and lifted the patient's abdominal folds.
*While wearing her contaminated gloves retrieved paper towels from the patient's bathroom and placed them on the patient to catch potential drainage.
*She used a gauze dressing and irrigation to cleanse the abdominal wound site.
*Without changing her contaminated gloves used a cotton tipped applicator to pack dressing into the abdominal wound, put a sterile gauze dressing over the wound, and removed her gloves.
*Without performing hand hygiene taped the dressing in place, removed her gloves, and used hand sanitizer.
*She gathered the trash, put in a new trash can liner, lowered the height of the bed, handled the patient's opened pudding cup and phone, and put the overbed table within the patient's reach.

4. Interview on 9/2/11 at the conclusion of the above observations with the unit supervisor revealed:
*Staff should remove contaminated gloves and perform hand hygiene after coming in contact with contaminated items and prior to touching clean items or linen.
*Isolation gowns should be removed prior to leaving an isolation room.
*Hand hygiene was important to prevent the potential transmission of microorganisms.
*All the patients listed in the above observations were on contact isolation.

5. Observation on 9/2/11 at 1:32 p.m. of patient 6 in the operating room revealed:
*While wearing a pair of clean gloves RN D removed the patient's dressing from the operative site. The operative site was the patient's venous access device and surrounding skin.
*Without changing her contaminated gloves and performing hand hygiene did the following:
-Assisted anesthesia to retuck the patient's left arm.
-Prepped the patient operative site with Chloraprep and then removed her contaminated gloves.
*While wearing clean gloves RN D picked up contaminated sponges with her hands to complete the sponge count, removed her contaminated gloves, did not perform hand hygiene, and continued documenting on the computer.
*The foam pink pillow headrest used by the patient during the case was saved for later use. Interview at the time of the observation with the unit manager confirmed the headrest should have been discarded after use during patient 6's procedure. The unit manager revealed the foam pink pillow headrest was a single use item.

Review of patient 6's medical record revealed the Hickman venous access was being removed due to it being infected. A microbiology report dated 8/29/11 revealed the enterobacter cloacae complex as the organism.

6. Interview on 9/2/11 in the afternoon with the infection control specialist confirmed staff should be changing gloves and performing hand hygiene after coming in contact with contaminated items/areas. The bed was not an appropriate place for a dressing to lay during a dressing change. Establishing a clean area on the overbed table would have been more appropriate.

7. Review of the provider's revised August 2010 Infection Prevention and control policy revealed nursing services had the responsibility for implementing the practical aspects of infection prevention and control. The policy stated "They must perform all procedures necessary for prevention, containment, and control of infections. They are the only persons in the hospital close to the patient every hour of the day and can provide continuous professional supervision with respect to infection control."

Review of the Association for Professionals in Infection Control and Epidemiology, 2009 Edition, revealed:
*Page 19-3 - Indications for hand hygiene and/or handwashing included:
-Before and after direct patient care.
-Before putting on gloves.
-After contact with patient intact skin.
-After contact with objects and equipment in the patient's immediate environment.
-When moving from a contaminated body site to a clean body site during patient care.
*Page 70-12 - "Failure to perform appropriate hand hygiene is generally considered to be the leading cause of MRSA spread and HAIs caused by MRSA."