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A. Based on observation, staff interview and review of medical records it was determined the registered nurse (RN) failed to ensure isolation precautions were implemented for five (5) of five (5) current patients reviewed and observed who required isolation precautions (patients # 2, 3, 5, 6 and 11). This failure creates the potential for all patients and/or staff and visitors to be placed at risk for infection transmission.

Findings include:

1. Observation of the isolation sign outside the door of patient #3 at approximately 0910 on 11/15/11 revealed the patient was on contact precautions isolation.

2. The Patient Care Assistant (PCA) #1 was observed entering and then leaving the room of patient #3 at approximately 0930. She was not wearing any personal protective equipment (PPE). She stated she was just checking the room and therefore no PPE was required. She was asked how she knew when to use PPE and what PPE was required. She stated she asked RN #1 and the RN told her only gloves were required. She stated she had worn gloves when she gave the patient his bath earlier that morning. She also noted she placed his linens in a disposable laundry bag. She was then observed to go back into the room and check the patient's water pitcher without using gloves.

Observation of the patient room from the doorway revealed no trash container inside the door into which used/soiled PPE could be discarded. The PCA stated when she uses gloves, she just puts them in the patient's trash can beside the bed or in the trash can in the bathroom.

3. The 2C Nurse Manager, who was present for this observation and interview, stated the nurse should have completed the isolation sign to indicate what PPE was required. She stated staff should wear a gown when contact is expected such as when bathing the patient. She also confirmed a trash receptacle should be placed just inside the doorway of the room into which staff could discard used/soiled PPE prior to exiting the room. The Nurse Manager noted the isolation signs were newer (implemented a few months ago) and staff may be confused by the format of the new signs.

4. Record review revealed patient #3 was admitted for observation on 11/08/11. The diagnosis was noted as "Recurrent C diff (Clostridium Difficile)." Review of laboratory results revealed the patient had specimens positive for C diff reported on both 11/9/11 and 11/10/11.

5. Observation was again conducted at approximately 1315 on 11/15/11. The isolation sign outside the room of patient #3 was observed to have check marks added to the sign. Hand washing, gowns and gloves were all marked as necessary precautions to be used with this patient.

6. At approximately 0920 on 11/15/11 an isolation sign was observed outside the door of patient #2 which revealed the patient was on droplet precautions isolation. The sign had check marks indicating the use of gloves, masks and hand washing was required. Gowns were not checked as required. The isolation cart, which contains a supply of clean PPE, was observed to be setting in the hallway outside the door. An open trash bag containing used/soiled PPE was observed hanging from the side of the isolation cart.

7. The 2C Nurse Manager, who was present for this observation, confirmed the contaminated trash should not be hanging on the isolation cart with the clean, unused PPE; nor should the open bag be outside of the patient room. She confirmed that used PPE should be removed and discarded before staff leaves the room.

8. During the midmorning of 11/15/11 the medical record for patient #2 was reviewed with the 2C Nurse Manager and the Director of Cardiovascular (CV) Services. Review of the record revealed the patient had a sputum culture positive for Methicillin Resistant Staphylococcal Aureus (MRSA) reported on 11/1/11.

Review of the Critical Test Result form revealed the Licensed Practical Nurse (LPN) noted she received the results at 0745 on 11/1/11. The form included a section for recording when (date and time) and who (Licensed Independent Practitioner) was notified of the results and whether orders were received. This section was not completed. Review of nursing notes revealed no documentation to reflect droplet isolation precautions were implemented by the nurse prior to 11/2/11.

9. Both the 2C Nurse Manager and the Director of CV Services agreed with these findings.

10. At approximately 1330 on 11/15/11 another observation was made of the isolation cart located outside of the room of patient #2. A disposable mask was noted to be hanging on the side of the cart. The Director of CV Services was present for this observation. She stated the mask should not be hanging on the cart and should have been discarded in the patient's room.

11. At 0900 on 11/16/11 the Infection Control (IC) Nurse was interviewed. The above observations were discussed with the IC Nurse. She stated she had previously noted some of the same problems when she made rounds. The IC Nurse also stated the isolation signs are not supposed to be check marked by staff. She stated that all PPE/Interventions listed on the isolation sign are applicable/necessary for the type of isolation posted.

During this interview the IC Nurse stated that patient #2 had been transferred to a negative air room the prior evening (11/15). She stated positive Acid Fast Bacilli (AFB) test results had been received and the patient was placed on Airborne Precautions until TB (tuberculosis) is ruled out.

12. At 0940 on 11/16/11 another observation of the isolation cart and signage for patient #2 was made. Observation of the isolation sign outside the room of patient #2 revealed she was now on Airborne Precautions. Some of the PPE/Interventions on the sign were check marked. Gown was not marked as required. Observation of the isolation cart outside the room revealed five N95 masks were on top of the cart. One of these masks had initials written on the mask. Two (2) more N95 masks were noted to be hanging on the side of the cart.

13. Interview was conducted with both the 4N Team Leader and Nurse Manager at approximately 0945 on 11/16/11. Both observed the masks which had been placed on the cart. Both stated the masks are disposable and should not be placed on the cart for reuse. The Team Leader indicated the staff initials on the one mask were the initials of PCA #2.

The isolation sign, which had been marked to reflect gowns were not indicated, was discussed with the Team Leader. She stated gowns should be used and indicated the isolation signs are new and stated that staff is confused about use of the signs. She removed and discarded the masks. The staff practice of marking only some of the PPE/Interventions, indicating only part of the PPE listed on the sign as necessary, was discussed with the 4 BN Nurse Manager. She agreed staff are confused about use of the isolation signs.

14. At approximately 1125 on 11/16/11 another observation of the isolation cart outside of the room of patient#2 was conducted. At this time another disposable N95 mask was observed to be hanging from the isolation cart.

15. At approximately 12 noon on 11/16/11 the isolation sign and cart were observed on the outside of the room for patient #11. Review of this isolation sign revealed he was on droplet precautions. The types of PPE/Interventions were not marked. The Critical Care Team Leader was asked when the patient was placed on isolation precautions as it was noted this patient was not on the hospital isolation list provided by the IC Nurse.

16. After review of the medical record the Team Leader indicated it could not be determined when the patient was placed on isolation precautions. The Team Leader did locate positive sputum cultures for patient #11 which were dated 11/11/11 and 11/13/11. She stated the laboratory is required to call and notify nursing staff of these results but no record of when that occurred or when the nurse placed the patient on isolation precautions was noted by the nurse in the medical record.

17. At approximately 1300 on 11/16/11 an observation was made of the isolation sign and isolation cart outside the room of patient #5. The sign reflected the patient was in contact isolation.

At 1305 on 11/16/11 observation was made of the isolation sign and isolation cart outside the room of patient # 6. The sign reflected the patient was in droplet isolation.

Both isolation signs had only part of the listed PPE/Interventions marked. Handwashing was not marked as a necessary Intervention on the Droplet Precaution isolation sign for patient #6.

18. Both the 2C Nurse Manager and Director of CV Services were present for these observations. Both agreed that observation of the isolation signs for these patients demonstrated the nursing staff are still confused related to how to use the isolation signs and what PPE/Interventions are required.

19. Another interview was conducted with the IC Nurse in the afternoon of 11/16/11. The 11/16/11 observations were discussed with her. She stated that all hospital staff are required to use a Powered Air Purifying Respirator (PAPR) mask when working with patients who are in Airborne Isolation. She also confirmed the N95 masks (observed on the isolation cart of patient #2) are disposable and are not to be used by hospital staff. She stated that education has been provided to staff related to the required use of the PAPR mask by hospital employees instead of the N95 mask. The IC Nurse stated staff has not cared for a patient in Airborne Precautions for some time and noted that she had gone to the floor and provided training related to proper use of the PAPR mask the prior evening (11/15/11).

20. Interview was conducted with the IC Officer in the afternoon of 11/17/11. She stated that all hospital staff are instructed in orientation that N95 masks are not to be used. She also confirmed that N95 masks require fit testing and no fit testing of staff has been conducted for some time.

B. Based on observation, review of policy and staff interview it was determined the RN failed to implement standard precautions for one (1) of one (1) patients who was observed to be suctioned (patient # 12). This failure places all patients and staff at risk for infection and/or cross contamination.

Findings include:

1. At 1250 on 11/16/11 RN #2 was observed to suction patient #12. The RN was observed to remove her gloves and leave the patient's room without washing her hands. She was then observed to go to the supply closet where she removed clean supplies. The surveyor then spoke with RN #2 as she was returning with the supplies. When this observation was shared with the RN she acknowledged she had not washed her hands. She stated she had been in a hurry to obtain supplies and return to the patient's room.

2. The policy "Isolation Precautions," effective date 2/22/11, was provided for review. It states in part: "Use Standard Precaution for the care of all patients...Wash hands immediately after gloves are removed..."

Based on observation and staff interviews it was determined the hospital failed to maintain a safe and sanitary environment.

Findings include:

1. On 11/14/11 at approximately 11:00 a.m. a tour of of Unit 2C was conducted. During this tour there was a door in the corridor that went into an area identified as Unit 2E. This unit was observed to be accessible to the public. At this time, a tour of Unit 2E was conducted. Several of the rooms on this unit were observed to be unoccupied patient rooms and were used for storage. The door to a public restroom on this unit was observed to be open. During an inspection of this room, two (2) bags of trash were observed on the floor. Also, two (2) commodes and the floor surface were observed to be very soiled. There was also a foul odor present in this room and in the corridor area near the room.

2. An interview with the hospital housekeeping manager on 11/14/11 at approximately 11:30 a.m., revealed that the public restroom on Unit 2E was not part of a scheduled cleaning routine.

3. An interview with the director of patient safety and quality on 11/14/11 at approximately 11:15 a.m. revealed that Unit 2E is classified as an unoccupied patient area and is not included in the hospital's routine environmental audits. Since Unit 2E is classified as an unoccupied patient area and not included in environmental audits, it should only be accessible by authorized personnel. Also, all the rooms on this unit that have been converted to storage rooms or are empty should be secured from unauthorized personnel. At the time of this investigation there were some rooms found unsecured and there was no signs posted to indicate that only authorized personnel should have access to Unit 2E.



30851

The hospital failed to designate an Infection Control (IC) Officer who develops and implements current policies for control of infections and communicable diseases (see Tag A 0748); A. The IC Officer failed to monitor activities related to maintenance of a sanitary hospital environment. The IC Officer failed to maintain current policies related to isolation procedures and monitor compliance with these procedures; B. The IC Officer failed to monitor activities related to maintenance of a sanitary physical environment. The IC Officer failed to monitor compliance with maintaining safe air handling for airborne infection isolation rooms; C. The IC Officer failed to monitor both the activities related to mitigation of risks associated with patient infections present upon admission and other hospital healthcare-associated infection risk mitigation measures. The IC Officer failed to monitor: appropriate use of personal protective equipment including gowns, gloves, masks and eye protection devices; the use and techniques for "isolation" precautions and appropriate use of negative pressure isolation room equipment and portable air filtration equipment and staff education related to implementation and use of isolation procedures (see Tag 0749); The chief executive officer, the medical staff and the director of nursing (DON) failed to be responsible for implementation of a successful corrective action plan for problems related to isolation procedures identified by the Infection Control (IC) Nurse (see Tag 0756).
The cumulative effect of these systemic problems resulted in the hospital's failure to ensure provision of a sanitary environment and an active program for prevention and control of infections.

Based on review of documents and staff interview it was determined the hospital failed to designate an infection control officer who developed and implemented current policies for control of infections and communicable diseases. This failure creates the potential for the care of all patients to be adversely impacted.

Findings include:

1. Review of the current hospital Organizational Chart (9/12/11) revealed Infection Control was not reflected on the Chart.

2. A request was made for the job description of the Infection Control Officer. A job description for "Assistant Director of Laboratory," last revised 5/1/01, was provided. This job description did not reference the Infection Control Officer position or duties.

3. In the morning of 11/14/11 the Director of Patient Safety and Quality stated the Infection Control (IC) Officer also serves as Assistant Laboratory Director. A request was made for a job description which reflected the duties of the IC Officer. She stated she felt these duties were outlined in policy and would provide that policy.

4. The Infection Prevention and Control Plan, effective 6/28/11, was provided for review. It states in part: "The Infection Control Program is staffed by Infection Control Nurses, Infection Control Officer, and Clerical support."

5. Interview with the Assistant Laboratory Director was conducted in the morning on 11/14/11. She confirmed she also serves as IC Officer. She stated she works with two (2) IC Nurses. One nurse works at the Memorial Campus of the hospital and one works at the St. Joseph's campus of the hospital. She noted the IC Nurse at the St. Joseph's campus also has a responsibility for Employee Health.

6. In March of 2011 Camden Clark Memorial Hospital and St. Joseph's Hospital merged and Camden Clark Medical Center (CCMC) was created. CCMC consists of two (2) campuses: the Memorial and St. Joseph's campuses.

7. Review of current IC policies/procedures revealed many had not been revised since the merger to reflect the practice at St. Joseph's campus such as:

a. The Camden Clark Memorial Hospital Tuberculosis (TB) Exposure Control Plan, effective date 12/30/10, reflected it had not been revised since the merger of the two campuses. The Environment section of the plan referenced rooms available on the Memorial campus. The St. Joseph's campus was not referenced in the Plan.

b. The TB Protocol, dated 12/30/10, was provided for review. It had not been updated since the merger of the hospitals. The Protocol did not reflect the procedure for the St. Joseph's campus.

c. The policy for "TB Isolation Room-admitting and maintaining," effective date 12/30/10, revealed it had not been revised since the merger of the two campuses. The procedure referenced the rooms available for use on the Memorial campus. The procedure did not reflect the rooms available and/or the procedure for the St. Joseph's campus.

d. The policy for "Isolation Admissions," effective 12/27/10, revealed it had not been revised since the merger of the two campuses. The procedure referenced the room available for use on the Memorial campus. The procedure did not reflect the room available and/or procedure for the St. Joseph's campus.

8. The Camden Clark Memorial Hospital Environmental Tool Checklist was provided for review. In the afternoon of 11/14/11 the Director of Patient Safety and Quality stated this audit tool is completed monthly for all occupied hospital units. Review of the Infection Control practices section of the tool reveals the hospital is monitoring for evidence of "Universal Precaution procedures in place:" Review of the the Center for Disease Control (CDC) website revealed the 'Universal Precaution' standard was replaced by 'Standard Precautions' in 1996.

9. Interview was conducted with the IC Officer in the afternoon of 11/17/11. She confirmed that St. Joseph's Hospital policies became null and void at the time of the merger. She also acknowledged that all CCMC infection control policies had not been revised to reflect the differences in physical environment and practice at the St. Joseph's campus. The IC Officer agreed that Universal Precautions were replaced with 'Standard Precautions' by CDC at least fifteen (15) years ago.

A. Based on observation, review of policy and staff interview it was determined the Infection Control (IC)Officer failed to monitor activities related to maintenance of a sanitary hospital environment. The IC Officer failed to maintain current policies related to isolation procedures and monitor compliance with these procedures. This failure creates the potential for all patients to be placed at risk for infections.

Findings include:

1. Observations of isolation procedures and subsequent related staff interviews revealed nursing staff are not consistently implementing and maintaining isolation procedures at the St. Joseph's campus. Multiple breaks in isolation technique were observed and multiple Nursing staff and Managers voiced confusion as to how new isolation signs are to be used (See Tag A0395).

2. The policy related to how to implement isolation precautions using the Isolation Signs, which was implemented in August 2011, was requested. The policy "Standard Precaution," effective date 7/20/11, was provided for review. It stated the following regarding use of the signs: "Use of Door Signs-Patient Care rooms will have Transmission-based Precaution door signs located on the entrance door identifying the type of precautions to be used with list of appropriate PPE (Personal Protective Equipment).

3. Interview with the IC Nurse in the morning of 11/16/11 revealed she had previously identified some of the same problems identified by the surveyor, i.e., contaminated trash in bags hanging open on isolation carts and disposable masks hanging on isolation carts for reuse. She stated the isolation signs had been implemented in August 2011. She agreed the policy had not been revised since implementation of the new signs and acknowledged she may have misunderstood how the signs were to be used.

4. Interview was conducted with the IC Officer in the afternoon of 11/16/11. She stated she does not conduct infection control observations or rounds at the St. Joseph's campus. She stated she was not aware of the problems with isolation which had been previously identified by the IC Nurse.

B. Based on observation, review of policy and staff interview it was determined the IC Officer failed to monitor activities related to maintenance of a sanitary physical environment. The IC Officer also failed to monitor compliance with maintaining safe air handling for airborne infection isolation room. This failure creates the potential for all patients to be placed at risk for infections.

Findings include:

1. At approximately 0930 on 11/14/11 an observation was made of room 239 which was a semi private room. The 2C Nurse Manager stated the room had been empty since the prior day. The room had been terminally cleaned. Two (2) rolls of tape were observed in the room. This tape poses an infection risk to the patients who are next admitted to the room. The Nurse Manager acknowledged the tape should have been discarded when the room was cleaned.

2. The policy "Isolation Precaution in Hospital", effective date 2/22/11, was provided for review. It states in part: "Use Standard Precautions for all patients...Ensure that reusable equipment is not used for the care of another patient until it has been cleaned and reprocessed appropriately. Ensure that single-use items are discarded properly."

3. At approximately 1340 on 11/16/11 a latex free (allergy) supply cart was observed in the hallway outside the room of patient #13. Approximately twelve (12) inches of the laminate trim around the front edge of the cart was missing revealing a rough cork board like surface. The entire trim on both sides of the cart was missing revealing approximately twenty-four (24) inches of rough surface on either side of the cart. A non intact surface cannot be effectively cleaned. Use of this cart for patient supplies poses an infection hazard to patients and staff.

4. Observations of the isolation carts outside the rooms of patient's #2, 3, 5 6, and 7 were conducted in both the morning and afternoon of both 11/15 and 11/16/11. The carts were observed to have a painted surface which is heavily chipped. A non intact surface cannot be effectively cleaned. Use of these carts for patient supplies poses an infection hazard to patients and staff.

5. During the afternoon of 11/16/11 the IC Officer was interviewed and these observations were shared. She concurred with these findings, stating that no one had noticed the condition of the latex allergy cart. She also indicated she would like to get rid of the isolation carts.

6. Interview with the IC Nurse at 0900 on 11/16/11 revealed two (2) patients were in Airborne Isolation Precautions.

7. An observation of the Airborne Precautions provided to patient #2 was conducted at 0940 on 11/16/11. The patient was observed to be in a room with the door closed. No gauges or readings could be observed outside the room which indicated the room was providing negative air for Airborne Isolation. The 3 BN Nurse Manger was asked how the room is checked to ensure negative air flow is being maintained. She stated that Engineering checks the negative air flow.

8. The Director of Engineering was in the hallway outside the patient's room. He was asked how the negative air is checked to ensure it is operating properly. He stated the hospital has a contract with an outside vendor who checks the negative air annually. He was asked again how the hospital checks to ensure negative air is being provided to the patients. He stated the Infection Control Nurse performs those checks.

9. During the afternoon of 11/16/11 a joint interview was conducted with the IC Officer and the IC Nurse. The IC Officer stated that Engineering is responsible for checking to ensure that negative air flow is being provided. She was asked if this was occurring at the St. Joseph's campus. She did not know if monitoring of negative air flow was being performed on the St. Joseph's campus.

The IC Nurse then stated Engineering was not aware of their responsibility for performing checks of negative air flow on the St. Joseph's campus. She stated the Director of Engineering had just asked her for the policy for Negative Air Checks. She stated she provided him with the old policy, noting the policy had not been updated since the merger of the hospitals in March.

10. Interview was conducted with the Engineering Manager in the late afternoon of 11/16/11. He confirmed he had not been aware Engineering was responsible to monitor the negative air flow. He stated he had only been provided with the policy earlier in the day. The Manager confirmed the policy reflects that Engineering is responsible to monitor the Negative Air Flow daily.

The Manager stated that Engineering staff had set up patient #7 in Airborne Isolation on 11/14/11 with a portable air (HEPA) unit. He also confirmed the room that patient #2 was isolated in lacked a built in gauge or monitor. The Manger confirmed that no monitoring of negative air for these two patients had been performed. He stated that currently he has no way to monitor that negative air is being provided to the patients. The Manager stated that external gauges for monitoring would be purchased.

The Engineering Manager was interviewed again in the morning of 11/17/11. He stated the room (406)that Patient #2 was placed in for Airborne Isolation on 11/15 and 11/16/11 was not checked when the contact vendor performed the annual check for negative air.

C. Based on observation, review of policy and staff interview it was determined the IC Officer failed to monitor both the activities related to mitigation of risks associated with patient infections present upon admission and other hospital healthcare-associated infection risk mitigation measures. The IC Officer failed to monitor: appropriate use of personal protective equipment including gowns, gloves, masks and eye protection devices; the use and techniques for "isolation" precautions and appropriate use of negative pressure isolation room equipment and portable air filtration equipment and staff education related to implementation and use of isolation procedures. This failure places all patients, staff and visitors at risk for infection transmission.

Findings include:

1. Observations in both the mornings of 11/15/11 and 11/16/11 revealed numerous breaks in isolation technique related to the care of patients #2 and 3. See Tag A0395

2. The above referenced observations were discussed with the IC Nurse in the morning of 11/16/11. She acknowledged she had previously identified some of the same problems.

3. In the morning of 11/16/11 patient #2 was observed to be in Airborne Isolation on another floor. N95 masks were observed to be both setting on the isolation cart and hanging from the cart. Staff initials were observed to be written on one of the masks.

4. Interview was conducted with the IC Officer in the afternoon of 11/16/11. She stated all staff are taught in orientation that N95 masks are not to be used. She confirmed that N95 masks require fit testing and stated no fit testing has been conducted in some time. The IC Officer was asked if monitoring is being performed to ensure that negative air is provided. She stated she did not know if air monitoring was occurring on the St. Joseph's campus. She was unaware of the isolation problems which the IC Nurse had identified. The IC Officer stated she does not make rounds on the St. Joseph's campus. She also confirmed she does not participate in the infection control training provided annually to all staff.

5. During the course of the survey two (2) patients (#2 and 7) were placed in Airborne Isolation after receipt of positive Acid Fast Bacillis (AFB) test results. Review of both medical records revealed the preliminary test results took two (2) days to be completed and available. The IC Officer was asked how the hospital mitigates the potential infection risk to other patients, staff and visitors while awaiting test results for suspected tuberculosis (TB). She stated these cases are reviewed case by case. She stated the IC Nurse reviews a daily listing of tests ordered. The Nurse then reviews the record and in conjunction with the physician makes a decision as to whether TB is strongly suspected and the patient would then be moved into Airborne isolation to await test results in those cases.

6. During the late afternoon of 11/16/11 the IC Nurse was asked about this process. She said she did not get this daily list of tests. She stated she was not aware AFB testing had been ordered on these two patients and therefore had not reviewed the records nor conferred with the physician to determine if Airborne Isolation was warranted while awaiting the test results.

Based on observation, review of documents and staff interview it was determined the chief executive officer, the medical staff and the director of nursing (DON) failed to be responsible for implementation of a successful corrective action plan for problems related to isolation procedures identified by the Infection Control (IC) Nurse. This failure creates the potential for all patients, staff and visitors to be placed at risk for infection and/or cross contamination.

Findings include:

1. Observations on 11/15/11 revealed nursing staff failed to demonstrate competence in implementing isolation precautions for contact and droplet isolation. (See Tag A 0395).

2. Interviews with Nursing Managers on 11/15/11 revealed Nursing Management was confused as to how to implement isolation precautions. The Nurse Managers indicated the isolation signs were new and nursing staff was confused about the process (See Tag A 0395).

3. Interview was conducted with IC Nurse (St Joseph campus) in the morning of 11/16/11. The breaks in isolation technique and confusion regarding use of isolation signs which were observed by the surveyor on 11/15/11 were discussed. The IC Nurse stated she had identified some of the same problems in the past. A request was made for documentation of any steps which had been taken to address these problems. A request was also made for education which was provided to nursing staff related to the implementation and use of isolation signs.

4. Observations during the morning of 11/16/11 revealed nursing staff failed to demonstrate competence in implementing precautions for airborne isolation. (See Tag A0395).

5. Interviews with Nursing Managers and Team Leaders on 11/16/11 revealed the nursing staff were confused about implementation of the new isolation signs. (See Tag A0395).

6. Interview was conducted with the IC Officer in the afternoon of 11/16/11. She stated she was not aware of any problems with isolation procedures at the St Joseph campus.

7. During the afternoon of 11/16/11 the IC Nurse confirmed she had no record of training provided to nursing staff related to use of the isolation signs. She acknowledged that all nursing staff were not trained before the signs were implemented. She had no record of who was trained regarding use of the isolation signs. She also could provide no outline or overview of the content of the training which was provided.

The IC Nurse provided a memo which was sent to some of the Nursing Managers on 10/14/11. It stated: "Reminder: Procedure masks, used for Droplet precautions, are disposable after single use. Staff should not be hanging on isolation cart for future use since they are a single use item." Review of the memo revealed it was not sent to all nursing managers. It also was not sent to the Director of Acute Care Services or the Director of Cardiovascular Services/Interim Director of Specialty Services.

8. Interview was conducted with the Director of Cardiovascular Services in the morning of 11/17/11. She stated the facility has had no Chief Nursing Officer since May 2011. She stated she and the Director of Acute Care Services are sharing the Director of Inpatient nursing oversight duties for the St Joseph's campus. Currently the Vice President of Operations, who has a clinical background as a Physician's Assistant, is providing Administrative supervision for the vacant Chief Nursing Officer position. She stated she was not aware of the problems with isolation procedures which had been encountered by the IC Nurse.

The Director of Acute Care Services was interviewed in the late morning of 11/17/11. She reviewed the 10/1/11 memo sent by the IC Nurse. She confirmed it was only sent to part of the Nursing Managers and was not sent to any of the Nursing Directors. The Director of Acute Care Services confirmed she was not aware of the problems with isolation procedures which had been encountered by the IC Nurse.

9. No action plan was implemented regarding isolation technique problems which had been identified by the IC Nurse.