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Based on observation, staff interview, and review of facility policy and procedure, it was determined that the Infection Control Practitioner/Officer (ICPO) failed to ensure staff followed policy and procedures to prevent the spread of infection. Specifically, the ICPO failed to monitor, investigate, control, prevent, or decrease the opportunities for the spread of infection for one of four patients in isolation (Patient 16). Observation of four rooms posted with contact isolation precautions (used for infections, diseases, or germs that are spread by touching the patient or items in the room) that received a lunch tray showed dietary staff (Q and R) failed to follow isolation precautions for one of the four rooms (6513) on two different occasions. The failure to follow the facility's policy and procedure for infection control had the potential to increase the spread and risk of infections for all patients admitted to the facility.

Findings Include:

Review of the facility's policy titled, "IC4-3 Determination of Isolation," Revised October 2018, provided the following information: New admissions will be assigned the appropriate level of Isolation by the charge nurse at the time of admission. Patients with a history of MDRO (multidrug resistant organisms) infection/sepsis/ colonization will be placed into Contact Precautions. Appropriate signage will be placed. Appropriate patient-visitor education will be done. The IC practitioner will verify correct choice and implementation of isolation procedures.

Review of the facility's policy titled, "IC4-5" Revised October 2018, provided the following information: Specific Procedures-A sign reading "Contact Precautions" will be posted on the door and on the patient's chart. PPE will be available at the entrance to the room. Gowns should be worn. Masks. Hand Hygiene. Non-sterile gloves are to be worn and removed before leaving the room.

1. Observation on 01/07/19 at 11:20 AM showed Contract Dietary Staff Q entering room 6513, identified as a contact isolation room, without donning the personal protective equipment (PPE) gown, gloves, and mask available at the door of the patient room. There was signage on the door to room 6513 indicating the need for PPE. Staff Q entered the room carrying the lunch tray and placed it on the bed table at the patient's bedside. Staff Q then exited the room, without washing hands and continued to deliver lunch trays, to other patients, down the hallway.

Review of Patient 16's medical record on 01/08/19 at 11:35 AM indicated the hospital admitted the patient on 01/02/19 with a diagnosis of a pressure ulcer to the sacral region (situated at the upper, back part of the pelvic cavity). The wound was cultured and reported to grow Methicillin Resistant Staphylococcus Aureus (MRSA-an infection caused by bacteria that occurs in people who are in health care centers and hospitals) and Vancomycin-resistant Enterococcus, or vancomycin-resistant enterococci, (VRE) are bacterial strains of the genus Enterococcus that are resistant to the antibiotic vancomycin that commonly causes urinary tract, blood or wound infections). At the time of admission, nursing staff identified the wound infection and placed Patient 16 in contact isolation precautions.

During an interview on 01/07/19 at 11:25 AM, Registered Nurse (RN), Staff L, verified Patient 16 was placed in isolation precautions because of an infected wound. RN L confirmed the hospital's policy for contact isolation required staff to enter the patient's room wearing a gown, gloves, and mask and to remove the gown and gloves and dispose of them in the trash receptacle before exiting the patient room. The RN pointed out the black and white tape on the floor near the room doorway is a reminder for staff not cross the line without having the proper PPE on or removed before entering/exiting the doorway. RN L shared all staff and contract staff are to wear PPE in the contact isolation rooms.

2. A second observation on 01/08/19 at 11:35 AM, while reviewing Patient 16's medical record, contract Dietary Staff R entered room 6513, identified as a contact isolation room, without donning the PPE gown, gloves and mask available at the door of the patient room. Again the signage at the patient's door indicated the need for PPE and was disregarded by Staff R. Staff R entered the room carrying the lunch tray and placed it on the bedside table and exited the room without having donned PPE or washing hands.

Interview at this same time with Contract Dietary Staff R, verified that he/she forgot to look at the "Stop" sign (posted at the upper right corner of Patient 16's doorway) used to identify the patient room as an isolation room. Staff R shared he/she are trained to don the PPE (the gown, gloves, and mask) located in the dispenser on the patient doorway before entering the patient room and are required to remove it, discard PPE and wash hands before exiting the patient room.

During an interview on 01/10/19 at 11:00 AM with the Director of Quality Staff (DQS), Staff D confirmed the hospital uses the "Hand Hygiene PPE Audit Tool" with the requirement of 10 audits per week for a total of 40 observations/audits per month. The audit includes observations of patients in isolation, the type of isolation, observations of hand hygiene, use of PPE and was the PPE used correctly. Staff D verified the hospital performed one surveillance observation of dietary staff on 11/02/18 (a tray delivery) and one on 12/21/18 (kitchen staff). The DQS further confirmed that all contract staff are trained on PPE and isolation precautions and are required to follow the infection control procedures in place.

Review of the "Touchpoint Support Services," identified as the contract dietary services education material included the following information: "When to wear your PPE-Patient rooms: Contact precautions, Droplet precautions, Also when using or dispensing chemicals. Personal Protective Equipment- Gloves, Gown, Mask, N95 mask, Hand Hygiene, Rubber/vinyl aprons, Safety goggles and Face shield. Pictures of standardized signage was included in the education.