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Based on observation, interview, and record review, nursing staff failed to ensure one(1) of 2 sampled patients on isolation precautions (22 Tower) were placed on appropriate transmission-based based isolation precautions in a timely manner ( Patient # 8).

*Patient # 8 was admitted from the Emergency Department (ED) with possible active Tuberculosis (TB). There was a 8 + hour delay in placement of airborne isolation signage and appropriate personal protective equipment (PPE)/isolation cart outside her room. Patient # 8 was not placed in an airborne infection isolation room (AIIR) for almost 15 hours after she arrived on the inpatient nursing unit.

*Three (3) of 3 nurses were unaware they could initiate isolation precautions without a physician order.

Findings include:

Review of Centers for Disease Control (CDC) Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005, read: "Fundamentals of TB Infection Control: One of the most critical tasks for health care-associated transmission of M. Tuberculosis in health care settings is from patients with unrecognized TB disease who are not promptly handled with appropriate airborne precautions...within health care settings, TB airborne precautions should be initiated for any patient who has symptoms and signs of TB..."

Review of ED physician progress note for Patient # 8, dated 08-31-15 (3:19 p.m.) : "consider highly TB...( 2210) : concern for TB...needs to be in TB isolation.."

Observation on 09-01-15 at 10:30 a.m. revealed Patient # 8 in room 2206 with an "airborne isolation" sign on the door and an isolation cart containing PPE to include N-95 respirator masks.

Interview at the same time with Registered Nurse (RN) # 22, ( nurse assigned to her care) she said Patient # 8 was admitted the night before at 9:00 p.m. from the ED. Her diagnosis was "rule out TB." RN # 22 stated this current room was not a negative air presssure room. The facility was in the process of cleaning a negative air pressure room ( 2263) and making sure it worked properly. There had been another patient admitted to that room who did not require negative air pressure.

RN # 22 went on to say the night nurse was concerned about airborne precautions and called the resident about 3 a.m. this morning. RN # 22 said the resident told the night nurse to wait until the morning and get an airborne isolation order from the attending physician. RN # 22 said it was necessary to obtain a physician order to place a patient in isolation.

Review of Patient # 8's clinical record revealed a physician order for "airborne isolation" was obtained at 09-01-15 at 6: 51 a.m. RN # 22 said the isolation cart and airborne sign was placed outside the door at this time.

Interview on 09-02-15 at at 11:15 a.m. with Registered Nurse (RN) # 8, she stated it was necessary to obtain a physician order before placing a patient in any type of isolation.

Interview on 09-01-15 at 11:30 a.m. with infection control staff RN # 4, he stated there had been a big delay in placing this patient in airborne isolation precautions. RN # 4 said would investigate the reason for the delay.

Interview on 09-02-15 at at 10:45 a.m. with Registered Nurse (RN) # 34 ( nurse assigned to her care), he stated it was necessary to obtain a physician order before placing a patient in any type of isolation. he went on to say that Patient # 8 had been moved to a negative air pressure room about noon yesterday ( approximately 15 hours after admission to 22 Tower) .

Interview on 09-02-15 at at 11: 00 a.m. with Nurse Manager # 3 she stated the nurse should always be "better safe than sorry" and place the patient in precautions and obtain the order later.

Interview on 09-02-15 at 1:40 p.m. with Infection Control Practitioner (ICP) #9, she stated the facility policy did not require a physician's order to initially place a patient in isolation precautions. The reason for this was to ensure timely placement if TB was suspected. ICP # 9 went on to say she researched the delay in placing Patient # 8 into airborne isolation. She said the first breakdown seemed to be in the communication between ED to "bed board" placement. ICP # 9 could find no documentation that the need for airborne isolation was communicated. Normally, this communication was the beginning of the process to get patient placed in a AIRR and have appropriate PPE in place. In addition , ICP # 9 stated nursing staff education was needed with respect to physician orders and isolation precautions.

Review of facility policy titled" Standard and Transmission-Based Precautions-Infection Control," dated July 2015, read: "...Procedures:...3. Transmission-based ( isolation)precautions... Airborne...d. Identification and Documentation for Patient Placed on Transmission-based Isolation:...1. A physician, infection preventionist (IP), or registered nurse (RN) may initiate isolation precautions-based on a patient's assessment, symptoms, presenting information...to promote early identification of patients who require isolation...f. Patient placement:... iii. Patients who are placed on Airborne Infection Precautions require a negative pressure room. Make sure the negative pressure room door remains closed at all times..."