HospitalInspections.org

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.