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Based on medical record review, staff interview, review of policies and procedures and patient observations; the hospital failed to ensure that the staff followed the Isolation Precautions policy and procedure to initiate the correct type of isolation (Contact Isolation) in 1 patient (Patient 5) that was identified with an infection; and 1 physician(Physician C) failed to follow the facility Burn Unit Contact Isolation Precautions of wearing the correct PPE (personal protective equipment-gown and gloves) for 1 of 3 direct observations on the 16 patient unit currently under contact isolation precautions. Physician C did not follow Isolation Precautions when entering a patient room in Contact Isolation for 1(Patient 11). This failed practice had the potential to spread infections to all patients. The census on the first day of survey was 92.

Findings are:

A. A review of Patient 5's medical record identified that the patient was admitted on 7/5/19 with Diabetic Ketoacidosis (DKA) a life-threatening problem that affects patients with diabetes; airway malacia (A condition where the trachea and bronchus (tubes for breathing leading to the lungs) are floppy and cannot stay open with breathing at times.); and a history of MRSA (Methicillin-resistant Staphylococcus Aureus- a bacteria that causes infections but are resistant to commonly used antibiotics) infection pneumonia in 6/2019 requiring hospitalization.

A review of the laboratory cultures and physician orders for Patient 5 revealed:
-On 7/7/19 the patient had a bronoscopy (looking at the lungs and airways through a lighted tube) and a Bronchial Culture was obtained and sent to the laboratory.
-The results of the Bronchial Culture was received on 7/10/19 at 12:40 PM which identified the critical result of MRSA.
-The physician was notified of the critical result of MRSA in the lungs. The physician ordered Droplet Isolation (isolation precautions for germs that are spread by coughing and sneezing) on 7/10/19 at 2:14 PM.
-The medical record identified that the isolation was changed to Contact (isolation precautions for germs that are spread by touching the patients or items in the room) and Droplet Isolation on 7/15/19 at 8:00 AM.

An interview with the Infection Control Preventionist on 7/21/19 at 11:45 AM revealed , on 7/15/19 Patient 5's culture results came to (gender) attention on a report. The Infection Control Preventionist then checked the patients medical record and noted that Patient 5 was in Droplet Isolation. The Infection Control Preventionist stated, "I than added Contact Isolation and contacted the nurses caring for the patients. Per the policy (Isolation Precautions), Patient 5 should have been put in Contact Isolation on 7/10/19." When verified that Patient 5 was placed in the incorrect isolation precautions, the Infection Control Preventionist stated, "Yes, for 5 days."

A review of the Isolation Precautions Policy 6114147 last revised 5/2019 revealed,
-Contact Isolation is used in addition to Standard Precautions for patients known or suspected to be infected or colonized with epidemilogically important organisms that can be transmitted via direct contact with the patient or the patient's environment, including but not limited to active infection with a Multi-drug resistant organism (MDRO).
-Only patients with active MRSA or VRE [Vancomycin resistant Enterococci infections-bacteria in the intestines that becomes resistant to the antibiotic. ] (not history only) will be placed in isolation for the duration of their illness.


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B. All 16 rooms on the Burn Unit contained Isolation signage on room entry door and a hanging tote of supplies with foam hand cleaner, yellow disposable gowns and boxes of disposable gloves.

On 7/22/19 at approximately 11:05am an observation of Physician C entering the room of Patient 11 without following facility contact precautions. Physician C failed to use hand cleaner and don gown and gloves when entering the room. While in the room Physician C proceeded to end of Patient 11's bed and lifted up bed sheet and blanket at foot of bed, visited with patient and left the room without handwashing.

Interview with Burn Unit Director on 7/22/19 at 10:20am revealed one patient on unit remains positive for CRE (Carbapenem-resistant Enterobacteriaceae) and contact isolation precautions are in place for all 16 patients on the unit, requiring medical staff, nursing staff and all visitors who enter room to foam clean hands, put on a disposable gown and gloves to protect the patients and for everyone's safety.