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Based on observation, record review and interview the facility failed to ensure patients with isolation precautions received care in a safe setting for two of two patients observed with infection precautions.

Facility Policy:
Isolation 01.19
Contact Precautions will be used, or specified patients known or suspected to be infected for colonized with epidemiologically important microorganisms that can be transmitted by direct contact with patients and or skin to skin contact that occurs when preforming patient care activities that require touching the patient's dry skin or indirect contact (touching) with environmental surfaces of patient care items in the patient's environment

Extremely Drug Resistant Organism Precautions
Visitors: Limit to the immediate family and require isolation attire (gowns/ gloves) and require hand hygiene to enter and leave the room.

During the initial tour 5/13/22 at 1040 Unit 4 ICU was observed to have two rooms (room 4035 patient #F and room 4044 patient G) with visitors in each room, at the patient bedside.
Both rooms had isolation signs and PPE affixed to the room doors.
Patient F was admitted 5/11/22 with diagnosis of Status Epilepticus (seizures), contact MRSA (Methicillin Resistant Staph Aureus) and was on a ventilator. There was an order dated 5/12/22 for: Contact Isolation by Physician # 22.

At 1045 Dr. #8, Neurologist was observed to enter room 4035 to see patient F. He opened the door and bypassed the warning sign and E on the door. The room already had a male visitor present, in street clothing without any PPE, at the bedside. This surveyor asked the patient's nurse (# 12) if physicians should be entering isolation rooms without PPE. She responded they should not and entered room 4035. Shortly after the MD and nurse exited and was assisted to don a gown and gloves before reentering the room without PPE. She stated the visitor was tall and large in stature and because she was smaller than many, she felt a bit fearful approaching him. This surveyor asked a male RN on the floor to enter the room with nurse #12. They brought the visitor PPE which he donned in the room.

Patient G was admitted 5/11/22 with diagnosis of Type 1 diabetes, anemia and Extremely Drug Resistant Organism. There was an order dated 5/12/22 for: Contact Isolation by Physician # 22. Patient G had a female visitor seated at the bedside in street clothing without any PPE.

Both rooms had isolation signs and PPE affixed to the room doors.

These rooms and visitors were observed and confirmed by Staff # 4 RN, Quality Safety Specialist.
Interview on 05/13/2022 at 1057, staff RN # 12 stated there is no visitor education on isolating or PPE need.

Interview on 05/13/2022 at 1115, staff RN # 14 stated she was unaware of routine visitor education on isolating or PPE need occurring. She stated she had told the visitor for room 1040 the need for PPE and what to wear but the visitor had ignored it today. She stated she had not documented the education.

Interview 05/13/2022 at 1055, staff #4 Quality Safety Specialist stated there is no policy for education or direction of visitors on PPE use when visiting patients with isolation precautions.