HospitalInspections.org

Based on observation, interview, record review and a review of facility documentation, the facility failed to ensure that training programs for infection prevention were effective to address problems identified in policy and required practices for2 of 7 sampled patients (#1 & 7).

Findings:

1. During observation patient #1's room on 5/13/19 at 10:55 AM, it was noted that the room had signage which indicated that contact precautions were in force. The container for used linen was not in the patient's room. Instead, it was just outside of the door. At this time, the Director of Nursing (DON) confirmed the observation.

Patient #1's medical record revealed that she had a diagnosis of Clostridium Difficile. "Clostridioides difficile (also known as C. diff) is a bacterium that causes diarrhea and colitis (an inflammation of the colon)." (cdc.gov). A review of facility process "Handling and Transportation of Soiled Linen" read, "Soiled linen should be placed in a covered linen bag or cart to transport from the room. Laundry collection containers are to remain covered when not in use. They are not to be left in hallways unless in use." Thus, the facility was not in compliance with this approved process. During an interview of the DON on 5/13/19 at 1:50 PM, she confirmed the finding.

2. During observation of the vacant room of patient #7 on 5/13/19 at 10:58 AM, signage indicated that Contact Precautions was in place. The text of the sign read, "Wear gown and gloves prior to touching the patient or their environment. Remove and discard in room before exiting." At this time, environmental services aide (ESA) A entered the room. He did not put on any personal protective equipment, such as a disposable gown and gloves. During an interview of ESA A on 5/13/19 at 11:01 AM, he stated that he had been trained to put on personal protective equipment upon entering rooms which had signage indicating that contact precautions were in place.

ESA A's personnel file revealed that he was hired on 10/06/14, and was trained on infection prevention on 10/06/14. Regarding the justification for patient #7's room having contact precautions, a review of her medical record revealed that she had a diagnosis of Escherichia Coli in the "urine line." "Escherichia coli (abbreviated as E. coli) are bacteria found in the environment, foods, and intestines of people and animals." (cdc.gov). ESA A was in violation of the posted requirement to wear gown and gloves prior to touching the patient or the patient's environment.

On 5/13/19 at 1:50 PM, the DON confirmed the finding.