HospitalInspections.org

Based on facility policy review, medical record review, observation, and interview, the facility failed to follow infection control guidelines during observations of one (unit A4) of three units toured.

The findings included:

Review of facility policy Isolation Precaution Procedure, last revised on 7/2015, revealed "...Contact Precautions...requires the use of gown and gloves to enter the room regardless of patient contact..."

Medical record review revealed Patient #1 was admitted to the facility on 9/7/15 for diagnoses including Below the Knee Amputation, Vancomycin Resistant Enterococcus, Possible Gastrointestinal Bleed, Chronic Respiratory Failure, and Septic Shock.

Medical record review of a physician's order dated 9/7/15 revealed "...Contact Isolation...continuous..."

Observation during tour of the facility with the Vice-President of Patient Care Services and the Safety/Accreditation Coordinator on 9/22/15 at 3:14 PM, revealed Patient #1 had Contact Isolation signage posted on the door. Continued observation revealed Registered Nurse (RN) #1 was at the bedside of Patient #1 and was not wearing any personal protective equipment (PPE).

Interview with RN #1 on 9/22/15 at 3:16 PM, outside the patient's room, revealed "he has VRE [Vancomycin-resistant Enterococcus, type of bacteria that can be spread from one person to another through casual contact]...I took my thing [PPE] off...alarm sounded and I went back in without putting back on..." Further interview confirmed the RN was aware the patient was in contact isolation and the RN was not wearing PPE.

Interview with the Manager of Infection Control on 9/23/15 at 12:40 PM, in the conference room, confirmed RN #1 was not following facility policy if not wearing PPE in a contact isolation room.