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Based on observation, staff interview, medical record review and facility policy review, the facility failed to maintain an Infection Control Program designed to help prevent the spread of infection by ensuring the use of transmission-based precautions (procedures to prevent the spread of infectious disease) were communicated to personnel and visitors through the use of appropriate posting of signage for 1 (Patient # 4) of 2 sampled facility patients on transmission-based precautions. The facility also failed to ensure adequate Infection Control prevention measures were in place for 4 (Patient Samples #1, #3, #4 and #11) out of 12 sampled patients. The failed practice did not assure infection control best practices were evaluated, addressed, revised and/or updated, per policy.

The findings include:

First observation made on 7/28/16 at 10:35 AM:
During the initial tour of the facility, Surveyor toured all 3 hallways in the Progressive Care Unit (Rooms 3101-3113, 3201-3212 and 3301-3308). It was verified with the Charge Nurse that there were 4 patients requiring contact precautions. There were no contact precaution signs observed on any of the doors.

An interview with the Charge Nurse (Employee A) on 7/28/16 at 10:40 AM: The Charge Nurse stated Room 3210 is on Contact Precautions. Contact Precaution rooms require special instructions prior to entering the patient rooms (Use Personal Protective Equipment, PPE). Additionally, Charge Nurse confirmed that Rooms 3212, 3302 and 3308 were also on contact precautions.

There was a discrepancy with the doctor's orders and what was actually observed by Surveyor for Room 3210. The doctor ordered contact precautions for Patient #1 in Room #3210.

Upon direct observation of Room 3210, Housekeeper was in the room cleaning with no awareness of contact precaution status. This room was one of the rooms previously stated to be on contact precautions. When this was pointed out, the nurse caring for patient stated patient was not on contact precautions. Information was conflicting. They corrected this by discontinuing order for Contact Isolation.

The next rooms observed, Rooms 3212, 3302 and 3308, also revealed that patients should have been on contact precautions and were not. It was previously noted by the Charge Nurse that these rooms were contact precautions. Based on observations, contact precaution measures were not carried out for these rooms. Upon further clarification by Surveyor, these patients did not need contact precautions. Information was conflicting.

Next observation made on 7/28/16 at 11:44 AM:
When surveyor initially toured the Unit at 10:35AM, Room 3301 (A different room not mentioned previously) did not have a Contact Precaution sign. At 11:44AM, patient had Contact Precaution sign on same door, and Personal Protective Equipment and Supplies were placed for staff and visitors near the patient's room. The Nurse (Employee C) walked by the room stating, "Are you kidding me."

In an interview with the Nurse (Employee C), when asked why Room #3301 was placed on Contact Precaution, she responded, "I honestly don't know. It was not there before. I will get back to you on that."

During that interval, Surveyor interviewed another patient, Patient #3, in Room 3301 at 12:05PM. Patient and her husband were present in room. Surveyor inquired about the signage outside patient's door for Contact Precautions and Personal Protective Equipment, PPE and Supplies available. Patient #3 responded, "Nobody was wearing gowns before." She stated, "I am not contagious." The husband was also present during the interview and agreed with his wife. He stated, "We were not made aware about that." " She does not have any infection."

After interview with couple, Surveyor returned to Nurse (Employee C) to follow-up at 12:15PM. She confirmed through review of the medical record that the patient in Room 3301, Patient #3, should not have been on Contact Precautions. Signage was placed on wrong door. Surveyor pointed out discrepancy to Charge Nurse, and it was immediately removed.

Surveyor mentioned to Charge Nurse that observations showed that no patients should be on actual contact isolation. She agreed and stated, "We usually don't have patients on Contact Isolation unless necessary." The previous contact isolation information provided was retrieved from the Electronic Medical Record (EMR).
Last observation made on the 2nd Floor Medical Unit on 7/28/16 at 1:44 PM:

Surveyor observed no signage outside patient's door for Contact Precautions for Room #2205 (Patient #4). There was Personal Protective Equipment and Supplies available for staff and visitors near the patient's room. Surveyor could not locate nurse in the area during this observation. An interview with the Charge Nurse (Employee D) at 1:55PM, confirmed that this same patient should be on Contact Isolation. This was also confirmed through surveyor's review of doctor's orders. When asked if there is signage on the door, no response was given. Surveyor observed Charge Nurse put a green sticker signage outside patient's door for Contact Precautions.

Care Plan review revealed, "Isolation Precautions" was identified with a goal to be free of infection. Intervention included, "Standard Precautions." Surveyor needed to ask for clarification with Performance Improvement Coordinator, who assisted the surveyor during record review. She agreed it was a mistake and that Standard Precautions was not the appropriate documentation.

The hospital's "Infection Control Policy" (Policy #012), documents the following procedures were noted:

1. Patient placed in private room. A transmission-based precaution sign is placed outside the patient's room by the nursing staff.

2. Infection Control will continue to monitor the infectious stage of the patient. The patient will remain on the transmission-based precautions until cleared per policy for discontinuing Isolation Precautions.

3. Patient with history of MDRO are at high risk for remaining colonized and therefore, transmission-based precautions will remain in place for every patient with history of MDRO within one year from positive MDRO diagnosis, or until removed per policy for discontinuing Isolation Precautions.

4. Patient and family will be educated on this MDRO policy; what precautions will be taken and infection prevention strategies, including use of PPE and hand hygiene. This education will be documented in the EMR.

5. Procedure guideline. Standard precautions should be used during all patient encounters at all points of healthcare delivery. Use contact precautions for all patients identified as colonized or infected with an MDRO.