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A. Based on document review, observation and interview, it was determined for 1 of 3 staff (E#4) in a contact isolation room, the hospital failed to ensure the proper PPE (personal protective equipment) was worn as required by policy.

Findings include:

1. Hospital policy titled, "Transmission Based Precautions (released 5/2015)" required, "Contact Precautions: ... Gloves - a. wear gloves whenever touching the patients intact skin or surfaces and articles in close proximity to the patient (e.g., medical equipment, bed rails). ... Gowns - a. wear a gown whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the patient."

2. During an observational tour of the High Acuity Unit (HAU) on 7/15/15 at 1:00 PM the following was observed:

- 1:15 PM - E#4 (respiratory therapist) was noted to be in room #1 (patient identified on contact isolation) performing respiratory bagging on the patient not wearing a gown or gloves.

- 1:50 PM - E#4 returned to room #1, after patient had been transferred to another room and prior to the room being cleaned, and took the respirator and other respiratory equipment out of room not wearing gloves.

3. During an interview on 7/15/15 at approximately 2:00 PM, the Nurse Manager (E#3) stated, "He should have been wearing gloves both times he entered the room, and a gown definitely should have been worn."

B. Based on document review, observation and interview, it was determined for 2 of 4 (E#4 and #5) staff in isolation rooms, the hospital failed to ensure hand washing was performed as required per policy.

Findings include:

1. Hospital policy titled, "Hand Hygiene (released 5/2015)" required, "Five moments for hand hygiene will be performed as follows: ... after touching a patient ... after touching a patients surroundings/environment"

2. During an observational tour of the High Acuity Unit (HAU) on 7/15/15 at 1:00 PM the following was observed:

- 1:15 PM - E#4 (respiratory therapist) was noted to be in room #1 (patient identified on contact isolation) performing respiratory bagging on the patient not wearing a gown or gloves. E#4 never performed hand hygiene before leaving the room and going down the hall to another unit, touching doors and equipment along the way.

- 1:40 PM - E#5 (rehabilitation staff) was noted to be in room #2 (patient identified on contact isolation) removing isolation gown and leaving room. E#5 did not perform hand hygiene prior to proceeding to next task.

3. During an interview on 7/15/15 at approximately 2:00 PM, the Nurse Manager (E#3) stated, "Hand hygiene should have been performed by both staff members."