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Based on record review, observation, and interview it was determined for 7 of 13 patients in isolation (Pts #2, #5, #7, #8, # 9, #10 and #11) the Hospital failed to ensure staff followed infection control policies and procedures related to education of patient/family, personal protective equipment (PPE), and dedicated equipment. This has the potential to affect all patients receiving care.

Findings include:

1. The hospital policy titled "Transmission Based Precautions " (supercedes: 7. D. dated 1/05/2001) was reviewed on 3/9/2015 at 1:00 PM. Policy notes, " 2. Contact C (clostridium) Precautions: b. Don gown and gloves before entering the patient room...c. Remove gown and gloves when finished caring for the patient."

2. An observational tour was conducted on 3/9/2015 at 9:50 AM -11:20 AM on Surgical/Neurological Unit with E #8 (Director of Medical/Acute Nursing). Pt # 9's record was reviewed on 3/10/2014. Pt #9 was admitted on 2/28/2015 with the diagnosis of acute respiratory arrest-seizures. Pt #9 was placed in Contact C isolation for history of clostridium difficile toxin. E #6 (physician) entered Pt #9's room without putting gloves on and sat at patient bedside.

3. An interview was conducted with E #8 at 9:50 AM. E #8 verified the observation and stated "Hospital policy of infection control was not being followed."

4. During the observation tour conducted on 3/9/2015 at 9:50AM - 1120AM on the Surgical/Neurological Unit with E #8, E #7 (physician) entered Pt #9's room without following isolation precautions posted on the wall. E #7 did not put on a gown or gloves when entering Pt #9's isolation room.

5. An interview was conducted with E #8 on 3/9/2015 at 9:55 AM, E #8 verified the observation and stated, "Hospital policy of infection control was not being followed."
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6. The policy titled "Infection Control Manual Category Selected Diseases and Conditions Multi Drug Resistant Organisms Methicillin-Resistant Staphylococcus aureus (MRSA), Vancomycin- Resistant Enterococcus (VRE) and Gram Negative Drug Resistant Organisms" (revised 9/17/2012) was reviewed on 3/9/2015 at 1:30 PM. Policy notes , " Under B. Precautions required: 2. gloves for entering patients room... 3. Gown for entering patient room". Under K. Visitors wear protective barriers and comply with protocol as per this policy...D 1. Patient care items (e.g. stethoscope, B/P (blood pressure) cuffs, thermometer, accucheck, etc.) are dedicated to the patient with MDRO (multi drug resistant organisms) colonization or infection....disposable items/supplies are used and disposed of after use (e.g. disposable blood pressure cuffs, thermometers...K. Visitors wear protective barriers and comply with protocol as per this policy".

7. Pt #11's record was reviewed on 3/9/2015. The record noted Pt #11 was admitted on 3/9/2015 with a diagnosis of hemotoma to right arm.. Pt #11 was placed in precautionary isolation for MRSA on 3/9/2015.

8. An interview was conducted with the nurse technician (E #9) on 3/11/2014 at 12:05 PM. E #9 stated, " I do not use a disposable thermometer to take Pt #11's temperature. I used the rolling machine to take temperature and clean the machine after I use it." (referring to a portable electronic monitoring machine for blood pressure, pulse and temperature). There is no disposable thermometer in Pt #11's room.

9. Pt #10's record was reviewed on 3/9/2015. The record noted Pt #10 was admitted for respiratory failure on 2/16/2015. On 2/19/2015 Pt #10 was placed in precautionary isolation for MRSA. On 2/28/2015 the final chest tube culture indicated positive for MRSA.

10. An interview was conducted with the significant other of Pt #10 on 3/9/2014 at 10:45 AM. The significant other stated, "Staff told me I don't need to wear precautions. Since we have been together so long and I live with Pt #10 I don't need to."

11. Pt #11's record was reviewed on 3/9/2015. The record noted Pt # 11 was admitted on 3/9/2015 with a diagnosis of hemotoma right arm. Pt #11 was placed in precautionary contact isolation for a history of MRSA.

12. An interview was conducted with Pt #11 on 3/9/2015 at 11:40 AM. Pt #11 stated " I did not receive any education for myself or family regarding infectious disease. Do I have an infection? They don't wear gowns or anything when they bring meals."

13. The policy titled "Isolation Precautions Responsibility" (supercedes:7. E dated 10/10/2009) was reviewed on 3/10/15 at 2:00 PM. Under section 4. Education of the patient and family/visitors. a, Inform the patient and family of the reason for the isolation...b. family/visitors are required to follow the same requirements for Personal Protective Equipment (PPE) as the healthcare staff...d. Instruct the family/visitor on the necessary apparel, how to put on, how to take off, and where to discard".

14. An observational tour was conducted on 3/9/2015 at 8:45 AM - 09:30 AM on the 6th floor Medical/Acute unit with E #8 (Director of Medical/Acute Nursing). Pt #8's record was reviewed on 3/10/15. Pt #8 was admitted on 3/8/2015 with the diagnosis of upper gastrointestinal bleed. Pt #8 was placed in Contact C (clostridium) isolation for precautionary measures. During the observational tour a female visitor was observed sitting on Pt #8's bed without PPE (personal protective equipment).

15. An interview was conducted with Pt #8 and female visitor on 3/8/2015 at 8:50 AM. The female visitor advised she had not received any education from staff and stated, "I have lived with Pt #8 for years, I don't need to."

16. An observational tour was conducted on 3/9/2015 at 8:45 AM 10:30 AM on the 6th floor Medical/Acute unit with E #8 (Director of Medical Acute Nursing). Pt #7's record was reviewed on 3/10/2015. Pt #7 was admitted on 3/9/2015 with a diagnosis of cellulitis. Pt #7 was placed in contact isolation on 3/9/2015 for precautionary isolation for MRSA. During the observational tour a male visitor was observed visiting Pt #7 in the isolation room without PPE.

17. An interview was conducted on 3/9/2015 at 9:15 AM with Pt #7's and male visitor. The male visitor (Pt #7's son) stated, Pt #7 has a history of MRSA in his toe and they had not received any education from the staff. "Should we be gowning up?"

18. Pt #5's record was reviewed on 3/11/2015. The record noted Pt #5 was admitted for diabetic foot ulcer on 3/5/2014 at 9:37 PM. Pt #5's record indicated precautionary contact isolation precautions were initiated on 3/6/2015 at 8:49 AM for history of an MRSA ulcer. Pt #5 received education on isolation precautions on 3/7/2015 at 9:00 PM.

19. Pt #2's record was reviewed on 3/11/2015. The record noted Pt #2 was admitted for acute renal failure 2/27/2015. Pt #2's record indicated precautionary contact isolation precautions were initiated on 2/27/2015 for a history of MRSA of the nares. Pt #2 received education on 2/28/2015.