HospitalInspections.org

Based on random observations, staff interview, and review of facility documents, it was determined the facility failed to ensure: 1) all staff change PPE (Personal Protective Equipment) in between patients and reusable equipment are disinfected in between patients; 2) appropriate door signage denoting the type of transmission precautions are placed for all patients on isolation precaution.

Findings include:

1. On 3/1/23 at 10:32 AM, during a tour of the Telemetry/Stepdown unit, Staff #12 (S12), a Nephrologist was observed exiting Room 612, an isolation precaution room for Candida Auris (C. Auris). S12 doffed (removed) his/her gloves and gown, performed hand hygiene, and proceeded out of the patient's room while still wearing his/her face mask, face shield, and stethoscope. S12 was then observed entering Room 617, another isolation precaution room for C. Auris. S12 was observed speaking to the patient at bedside with the same mask and face shield. S12 then used his/her stethoscope on the patient. Upon interview, S10, the Assistant Director confirmed that PPEs such as face masks and face shields should be changed in between patients. S10 immediately approached S12, reminded S12 to dispose of his/her used face mask and face shield. S10 also proceeded to wipe/disinfect S12's stethoscope using a PDI wipe.

2. On 3/1/23 at 10:39 AM, during a tour of the Stepdown CTICU (Cardiothoracic Intensive Care Unit), a random observation of patient rooms revealed that there was no contact isolation precaution signage on the following patient rooms:

Room 601 had a patient who was positive for MRSA (Methicillin-resistant Staphylococcus Aureus).
Room 603 had a patient who was positive for ESBL (extended spectrum beta-lactamase) in the urine.
Room 615 had a patient who was positive for C. Auris.

At 10:42 AM, upon interview, S10 confirmed that there should be signage on the doors for isolation precautions; S10 then proceeded to place contact isolation signage on the door of the patient rooms, Room 601, 603 and 615.

Review of facility document titled, "Procedure: Standard and Transmission-Based (Isolation) Precautions for Inpatients and Outpatients" (undated) states, " ... 2. Transmission-Based Precautions: Transmission-Based precautions are used for patients known to be infected or colonized with epidemiologically important pathogens that can be transmitted by Airborne, Airborne-Contact, Contact ... transmission. ... Contact: (staff to enter room; at a minimum wear gown and gloves. Eye protection as needed as per Standard precautions) ... 1. The unit shall ensure appropriate PPE is readily available. 2. Place sign on door. Appropriate signs which denote Transmission Precautions, contain necessary instruction for staff and visitors are to be displayed on the door for both cohorted and private rooms. ... 7. Patient-Care Equipment: ... Disposable single patient medical equipment such as stethoscopes, thermometers, blood pressure cuffs are preferred for patients on isolation. If not possible, ensure that reusable medical equipment is not used for the care of another patient until it has been cleaned and reprocessed appropriately. ..."