HospitalInspections.org

Based on observation, interview, and record review, the facility failed to ensure Registered Nurse (RN 1) secured her isolation gown (to protect the wearer from the spread of infection or illness if the wearer comes in contact with potentially infectious liquid and solid material) in the back before entering a patient's room and did not remove her N95 mask (a respiratory protective device designed to filter infective air particles) before leaving the anteroom (a small room to put on and take off protective equipment before entering or exiting the patient's room) for one of 25 sampled selected patient (Patient 22).

This failure had the potential to spread an infection.

Findings:

During an observation, on 11/17/2021 10:59 a.m., there were two isolation signs on Patient 22's room. One was for airborne isolation (applies to patients known or suspected to be infected with microorganisms transmitted by airborne droplets) and one for contact isolation (used when a patient has an infectious disease that may be spread by touching either the patient or other objects the patient has handled). RN 1 was observed inside Patient 22's room wearing an isolation gown that was not secured in the back.

During a concurrent observation and interview, on 11/17/2021 11:13 a.m., with RN 1, in the nursing unit hallway, RN 1 was observed exiting Patient 22's anteroom and walked down the hallway still wearing the N95 mask. RN 1 stated the N95 mask should be removed before leaving the anteroom but did not because she was in a hurry.

A review of Patient 22's History and Physical, dated 11/12/2021, a chest x-ray indicated, a large cavitary lesion measuring approximately 10 cm spanning the right mid and lower lung areas that could appear to be tuberculosis (a disease caused by bacteria that can spread through the air when a person with tuberculosis coughs, sneezes, or talks).

A review of the Physician's Order, dated 11/12/2021, indicated, Patient 22 was ordered to be on isolation airborne and contact precautions.

A review of the facility's policy and procedure titled, Standard Precautions & Transmission Based Isolation Precautions, dated 7/2019, indicated an isolation gown should be wrapped around the back and fastened at the waist. Respiratory protection is required to be removed after leaving the patient's room.