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Based on review of staffing/assignment sheets, policy review, and staff interview, the facility failed to ensure the facility policy for a Methicillin resistant staphylococcus aureus (MRSA) outbreak in the neonatal intensive care unit (NICU) as it relates to patient cohorting in an assignment (A0772). This affected all 16 patients who tested positive for an MRSA infection and/or colonization. The total sample size was ten medical records reviewed. The current NICU census at the time of the survey was 65.

Based on review of staffing/assignment sheets, policy review, and staff interview, the facility failed to ensure the facility policy for a Methicillin resistant staphylococcus aureus (MRSA) outbreak in the neonatal intensive care unit (NICU) as it relates to patient cohorting in an assignment. This affected all 16 patients who tested positive for an MRSA infection and/or colonization. The total sample size was ten medical records reviewed. The current NICU census at the time of the survey was 65.

Findings include:

A tour of the seventy-two bed neonatal intensive care unit (NICU) was conducted on 02/26/20. During the tour many rooms were observed to have signage stating "contact isolation" with carts outside the door. Interview with Staff B during the tour revealed these infants were all positive for methicillin resistant staphylococcus aureus (MRSA).

Staff A provided a timeline of events related to the MRSA outbreak in the NICU. Staff A stated the first infant was diagnosed with MRSA after a blood culture and left arm wound culture were identified as positive for MRSA on 12/21/19. The timeline revealed a second positive MRSA case was noted in January with a positive urine culture identified on 01/07/20 for Patient #2. Staff A further stated these infants were placed in contact isolation immediately after the positive results were identified. The timeline on January 7th revealed the NICU's outbreak policy states if two positives are identified within two weeks of each other to begin cohorting the assignments.

The facility policy titled, "Clinical Departmental Policy and Procedure" Newborn Intensive Care Unit (NICU), MRSA Management was reviewed on 02/27/20. The policy read, "screening for MRSA with nasal PCR occurs in the NICU under the following circumstances: 2. An outbreak occurs." The procedure directed the clinician to obtain the nasal PCR swab and place infants with a positive result in contact precautions. "Positive infants are cohorted in an assignment."

The practice of "cohorting staff assignments" was explained during interview with the Infection Preventionist (Staff A) on 02/27/20 at 11:50 AM. Staff A explained that when a caregiver is given an assignment for his/her shift in the NICU, every effort is made to assign only infected patients to that caregiver and not a mix of infected (or isolation patients) and non-infected (or non-isolation) patients. The NICU Director (Staff B) who was present at the interview explained there are a number of variables that will affect that effort, including the unit demographics: i.e., if two infants are in isolation at opposite ends of the unit (because of the timing of their respective admissions and their acuity), it's not always feasible to assign one nurse just those two infants and no others.

The facility's outbreak timeline revealed the facility started to cohort infants who were positive for MRSA on 01/07/20. The facility's staffing/patient assignment sheets were reviewed on 02/27/20. The staffing/patient assignment sheet for 01/07/20, 7 PM - 7 AM shift, revealed Patient #1, who had positive cultures for MRSA on 12/21/19 in the blood and left arm, was cohorted on the same assignment with Patient #2, who had positive cultures for MRSA on 01/07/20 in the urine. This assignment was cohorted together from 01/07/20 - 01/14/20 until Patient #1 was transferred during the night shift to the east wing.

The staffing/patient assignment sheet for 01/15/20, 7 AM - 7 PM shift, revealed Patient #1 was placed on an assignment with two other infants who were negative for MRSA. Patient #2 was placed on an assignment with two infants who were also negative for MRSA, but both later acquired it (Patient #5 and #11). The staffing/patient assignment sheet for the 7 PM - 7 AM shift revealed Patient #1 was placed on an assignment with two different infants, who again were negative for MRSA and Patient #2, was placed on an assignment with the same two infants who were negative for MRSA.

The facility timeline on 01/20/20 revealed a third positive MRSA occurred on 01/18/20 in a right thumb wound. On 01/21/20 all infants in the NICU had screenings completed with an additional five positive MRSA cases identified with plans to cohort these assignments.

The staffing/patient assignment sheet for 01/21/20, 7 PM - 7 AM shift, revealed two assignments where the infants were cohorted as policy instructs; however, Patient #1 was placed on an assignment with two infants who were negative for MRSA, Patient #2 was placed on an assignment with an infant who was negative for MRSA, and another positive MRSA case was placed on an assignment with an infant who was negative for MRSA.

The staffing/patient assignment sheet for 01/31/20, 7 AM - 7 PM shift, revealed Patient #1 was placed on an assignment with two infants who were negative for MRSA and then on then on the 7 PM - 7 AM shift, Patient #1 was placed on an assignment with two different infants who were also negative for MRSA .

The staffing/patient assignment sheet for 02/02/20, 7 AM - 7 PM shift, Patient #2 was placed on an assignment with an infant who was negative for MRSA and this assignment received a new admission during the shift, who again did not have MRSA.

The staffing/patient assignment sheet for 02/03/20, 7 AM - 7 PM shift, revealed Patient #1 was moved to a different room and was placed on an assignment with two infants who were negative for MRSA and then again on the 7 PM - 7 AM shift, the infant was again placed on an assignment with two infants who were negative for MRSA.

The staffing/patient assignment sheets from 01/07/20 - 02/04/20 were reviewed with Staff C on 02/27/20 at 11:00 AM. Staff C confirmed that the facility did not follow their policy for MRSA Management in the NICU with regard to cohorting assignments when a positive culture was identified.