HospitalInspections.org

A. Based on observation, document review, and interview, it was determined for 1 of 1 employee (E #2) observed caring for a patient on transmission based precaution, the Hospital failed to ensure personal protective equipment (PPE) was worn as required. This potentially affected any patient/staff member E#2 had contact with after leaving the isolation room.

Findings include:

1. On 3/23/16 at approximately 10:20 AM, an observational tour of the intensive care unit (ICU) was conducted. In ICU - 12, Pt. #9 was on contact precaution for multi-drug resistant organism infection. Pt. #9's sitter (E #2) was not wearing gloves or gown while inside the room of Pt. #9.

2. The policy titled "Transmission Based Precautions" (reviewed 3/13), reviewed on 3/24/16, required, "...a. Contact Precaution... iii. Gloves - required prior to entry to the room... v. Gown - Before entering the room if you anticipate contact with the patient or the environment.

3. On 3/23/16 at approximately 10:30 AM, an interview was conducted with the Director of ICU (E #1), who confirmed that E #2 should wear gloves and gown while inside the room of Pt. #9.


B. Based on document review and interview, it was determined for 1 of 10 personnel (E #4) files reviewed, the Hospital failed to ensure Tuberculosis (TB) screening was performed annually as required. This potentially affected an average of 120 patients in the emergency department (ED) E #4 cared for each month.

Findings include:

1. On 3/24/16 at approximately 1:00 PM, E #4's personnel file was reviewed. E #4 was a registered nurse (RN) hired in 2012 and worked in the ED. E #4 had a history of a positive TB test with the most recent TB screening done in 5/14.

2. The policy titled "Tuberculosis Control Plan" (reviewed 6/13), reviewed on 3/24/16, required, "...10. Employee Health Services is responsible for ensuring appropriate screening of all employees... for evidence of latent or active tuberculosis at the time of employment and repeated not less than annually as outlined in the facility's TB Risk Assessment".

3. On 3/24/16 at approximately 1:30 PM, the Chief Human Resources Officer (E #5) was interviewed who stated that screening for TB should be done annually.