HospitalInspections.org

Based on review of facility documents and medical records (MR) and interview with staff (EMP), it was determined that the facility failed to follow the policy to provide for the physical separation of isolation patients, and to provide education to family/patient of isolation patients for one of two medical records reviewed (MR1).

Findings include:


Review of Infection and Control Department Plan for 2017, revealed, " ... C. Prevention/Intervention. a. Education for Staff, Patients and Families ... iii. Education of the patients and their families is provided by nursing on an ongoing basis and documented in the patient chart. Infection Prevention and Control Department provides consultation to families with requests for additional information on infection-related topics. Patient education materials are available electronically. ... j. Methicillin resistant Staphylococcus aureus (MRSA). ii. Isolation Coding. 1. An electronic long-term isolation code is entered into the system that auto-populates the electronic medical record banner bar with 'MRSA' . 2. All patients with MRSA are placed in contact precautions and placed in private room or cohorted with another patient with matching organism codes."
1) Review of MR1 revealed the nursing unit was made aware of a positive MRSA culture on November 19, 2017 at 07:43. Further review of MR1 revealed no documentation of an isolation initiation form, and no documentation of patient or family education of MRSA isolation precautions.
2) Interview with Infection Control Nurse EMP3 revealed, "Once we receive a positive culture, it automatically gets paged to the unit bed board. On the weekend, it gets paged to the AOD (Administrator on Duty) and/or room assignment person. That initiates the isolation initiation form. Then a [isolation] sign goes up, and garb (personal protective equipment) goes on the door. ... The unit was aware on the 19th (November 19, 2017) at 07:43 of the positive MRSA culture. ... No, there is not an isolation initiation form, isolation education, or an isolation careplan for [MR1]."