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Based on observations, interviews, and facility record reviews, the facility failed to ensure the written Infection Control Policy and Procedures were implemented throughout the facility for 2 out 23 sampled patients (Patients #12 and Patient #13).

The findings include:


1). A random observation Employee A on 12/15/14 at 12:00pm while in Room #333 with the Assistant Chief Nursing Officer and the 3 West Charge Nurse revealed she was in the room drawing blood from a patient on contact isolation. Employee A's Personal Protective Equipment (PPE) was observed hanging off of her shoulders, below chest level. At 12:06pm, Employee A was observed reaching into their pockets under the isolation gown with gloved hands, after drawing blood from the contact isolation patient. Employee A proceeds to tie the top of her isolation gown with contaminated gloved hands.

An interview with Employee A on 12/15/2014 at 12:10pm revealed the facility's expectation is that staff don gown and gloves before entering the room of a patient on contact isolation. The PPE should be removed and hands shall be washed prior to leaving the room. Employee A stated that all equipment taken into the room should be disinfected with Sani-Cloth wipes before leaving the room. Employee A stated her gown fell down while she was in the room drawing blood. She stated, "I am not aware of what the facility policy says I am supposed to do". The facility's policies and procedures are available for review in the Nursing Station and in the Respiratory Therapy office. "I don't know how to locate the policy online".

A medical record review for Patient #12 revealed she was swabbed positive for MRSA of the nares on 12/11/4. The swab was officially resulted on 12/12/14.

An interview with the Assistant Chief Nursing Officer on 12/15/14 at 12:20pm revealed the facility does not have policy and procedural manuals in the nursing units; they are only available online throughout the facility.

An observation of Employee A on 12/15/14 at 3:12pm revealed that she is now able to locate the Infection Control and Isolation Policies online, using the facility's intranet.

A personnel file review of Employee A revealed she completed her annual Infection Control Training on 4/22/14.

2). A random observation of Employee B on 12/15/14 at 1:00pm, with the Assistant Chief Nursing Officer and the 3 Center Director, revealed Employee B, in Room 335, was in a contact isolation room without wearing an isolation gown. Employee B is observed cleaning a brown liquid substance from the floor near the bed with gloved hands. Employee B then removed his gloves and exited the room, carrying the Gluco-Monitor. Employee B returned the Gluco-Monitor to the nursing station charging base.

A medical record review of Patient #13 on 12/11/14 revealed the MRSA Screen was negative; it was verified on 12/13/14; however, the patient still remains on contact isolation.

An interview with Employee B on 12/15/14 at 1:06pm revealed that he is aware that he should have had on both a gown and gloves while in Room #335, because the patient is on contact isolation. Employee B stated that he is not sure why Patient #13 is on contact isolation; he was just helping another staff member. Employee B was asked by this Surveyor to retrieve the Gluco-Monitor and disinfect it using the facility-approved disinfectant.

An interview with the Chief Medical Officer on 12/15/14 at 1:15pm, while reviewing the medical record, revealed the culture screen should have cleared Patient #13 from contact isolation; however, the facility's policy is that a patient with a positive result less than 2 years old is placed on contact isolation. This patient had a positive result in 2013.

A personnel file review for Employee B revealed he completed his annual Infection Control Training on 7/3/14.

Reviews of the Infection Control and Isolation Policies and Procedures, with a last review date of 10/31/13, revealed facility isolation guidelines are consistent with the established recommendations of the Centers for Disease Control. Gowns will be worn to provide a barrier and prevent direct contact with a patient and their environment while under Contact Precautions. The gown shall be applied immediately prior to entering the room and removed prior to leaving the room. Additionally, gloves are required when entering any room under Contact Precautions. The use of gloves does not eliminate the necessity for hand hygiene. Gloves shall be discarded inside the room, and hand hygiene shall be performed before leaving.