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Based on observation, interview and document review, the facility failed to implement policies and procedures for contact precautions for 3 (#6, #8, #14) of 3 patients observed for this precaution, resulting in the potential for the spread of infectious agents to other patients and staff in the hospital. Findings include:

On 4/1/15 at approximately 1005, patient #6 was observed in contact precautions. Review of patient #6's medical record with Nurse Manager #D, on 4/1/15 at 1010, revealed that the patient was in contact precautions for Methicillin-Resistant Staphylococcus Aureus (MRSA) and Vancomycin-Resistant Enterococci (VRE). On 4/1/15 at 1015, Nurse #F was observed giving the patient patient #6 Morphine 1 milligram via Intravenous tubing. She utilized a carpujet syringe holder which she cleansed with the wall mounted hand sanitizer before removing from the room. When queried about cleanser, she stated, "that's what I use". Concurrently at 1020, Physician #F entered the room with a gown and gloves on, but sat on the patient's bed without having the back covered with the gown. It was noted that the physician's lab coat was in direct contact with the patient's linens.

Interview with the Chief Nurse (CNO) on 4/1/15 at 1025 verified that the physician should not have sat on the bed with the back lab coat exposed. Also, the CNO verified that there were approved cleansers for non-critical medical equipment. Review of the facility policy, on 4/1/15 at 1200, titled, "Cleaning and Disinfection of Non-Critical Patient Care Equipment/ Environmental Surfaces in Patient Care Areas", revised 2/26/15, with attached document "Available Cleaning Agents and Contact Times" (Non-Critical Medical Equipment), did not list hand sanitizer as an approved agent for non-critical medical equipment.

Observation of patient #8, on 4/1/15 at approximately 1100, revealed that the patient was in contact precautions. Physician #J was noted going in the patient's room with a gown on untied in the back. Record review of patient #8's medical record with Nurse Manager #I, on 4/1/15 at 1105 revealed that the patient was suspected to have VRE and/or "resistant e-coli". Further interview with the CNO at 1110 verified that the facility policy is for full gown cover up for contact precautions. Review on 4/1/15 at 1200, of (undated) policy titled, "Isolation Precautions", documented "Procedure to put on gown... Fully cover torso from neck to knees, arms to end of wrist, and wrap around the back. Fasten in back at neck and waist."

Observation of pediatric patient #14, on 4/2/15 at approximately 0930, revealed the patient to be in contact and droplet precautions. Two family members were observed in the patient's room without gowns or masks on. Interview with Nurse Manager #P, on 4/2/15 at 0935, revealed that, "Parents/family are allowed to be in the room without gowns and masks, that's our policy." Request for documentation in policy at that time revealed no such documentation. Review on 4/2/15 at 0945, of the (undated) facility policy titled, "Isolation Precautions", page 8, "Patient and Visitor Education", documented, "If visitors will have close contact with the patient or be visiting other patients, they should be instructed in the appropriate use of gowns, surgical masks, and gloves..."

Interview with the Infection Control Officer, on 4/2/15 at approximately 1400 verified that staff did not follow the facility policy and procedures in the above instances.