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Based on record review, staff interview, staff observations and review of the policy and procedures for infection control practices, the facility failed ensure infection control practices were followed for 4 of 8 patients (Pt 4, 5, 11 and 12) with current infections from a sample of 12 patients. The failure to follow the infection control policies and procedures had the potential to spread the infection to other patients, staff, and visitors.

Finding are:

A. A review of Pt 4's medical record revealed that patient was admitted on 9/9/21 with the diagnoses of Covid 19 positive infection (an infectious virus spread person to person); Pneumonia (a lung infection); Hypoxia (low oxygen levels in the blood); and encephalopathy (disease or damage to the brain causing mental dullness or confusion). Pt 4 was in Covid 19 isolation, which included the need for anyone having contact with the patient to have on Personal Protective Equipment (PPE) including a gown, gloves, goggles and a fitted mask. All staff entering the area must complete hand hygiene before donning (applying) PPE and immediately after removing PPE. The door to the room must be closed at all times and only opened when necessary for staff to enter the room.
An observation in the Intensive Care Unit (ICU) on 9/13/21 at 3:50 PM revealed that Pt 4 was sitting up in the recliner in the room. The patient had activated the call light. The registered nurse (RN A) was sitting outside the room with a fitted mask on. When the call light was activated, RN A went to Pt 4's room door and opened it (approximately 12 inches) far enough for the nurse to speak to the patient and answer the patient's question. RN A did not follow the isolation protocol of keeping the door closed unless protected with the PPE as directed.

The quality assurance nurse (QA RN) that accompanied this surveyor on the observation verified that RN A did not follow the isolation protocol.

B. A review of Pt 11's medical record revealed that patient was admitted on 8/31/21 with the diagnoses of Covid 19 positive infection; Pneumonia; Hypoxia; pregnancy and was on the ventilator (a machine to pump oxygen into the body) . Pt 11 was in Covid 19 isolation, which included the need for anyone having contact with the patient to have on Personal Protective Equipment (PPE) including a gown, gloves, goggles and a fitted mask. All staff entering the area must complete hand hygiene before donning (applying) PPE and immediately after removing PPE. The door to the room must be closed at all times and only opened when necessary for staff to enter the room.

An observation in the Intensive Care Unit (ICU) on 9/13/21 at 3:55 PM revealed a housekeeper in the room with the appropriate PPE on cleaning Pt 11's room. The housekeeper was seen opening the ICU room stepping out into the hallway without removing the PPE to grab articles off the housekeeping cart and returned into the room. The housekeeper did not follow the isolation protocol.

The QA RN that accompanied this surveyor on the observation verified that the housekeeper did not follow the isolation protocol.

C. A review of Pt 12's medical record revealed that patient was admitted on 9/13/21 with the diagnoses of Covid 19 positive infection; altered mental status, and hyponatremia (low sodium level). Pt 12 was in Covid 19 isolation, which included the need for anyone having contact with the patient to have on Personal Protective Equipment (PPE) including a gown, gloves, goggles and a fitted mask. All staff entering the area must complete hand hygiene before donning (applying) PPE and immediately after removing PPE. The door to the room must be closed at all times and only opened when necessary for staff to enter the room.

An observation in the Progressive Care Unit (PCU) on 9/13/21 at 3:58 PM revealed that Pt 12 was in room 206. The QA RN and this surveyor were standing outside Pt 12's room when a registered nurse (RN B) with only a fitted mask was witnessed going into Pt 12's room without full PPE and closed the door. RN B came back out of the room and stated "(RN C) was already in the room." When asked if Pt 12 was still in the isolation, RN B stated, "yes, I was responding to a safety issue." The QA RN and this surveyor did not hear any alarm or see a light on above Pt 12's door, and there was already a RN in full PPE present in the room with Pt 12.

The QA RN that accompanied this surveyor on the observation verified that RN B did not follow the isolation protocol.

D. A review of Pt 5's medical record revealed that patient was admitted on 9/13/21 with the diagnoses of Clostridium Difficile (C Diff) a contagious bacterium that causes severe diarrhea colitis (an inflammation of the colon) that is contagious. Pt 5 was in isolation that required staff and visitors to wear a gown, gloves and must wash hands with soap and water before exiting the room. The room and surfaces must be disinfected with bleach products. (Currently all staff and visitors are required to wear a mask.)

An observation in the Intensive Care Unit (ICU) on 9/14/21 at 4:30 PM revealed a visitor sitting in Pt 5's room in the recliner without the required PPE of a gown and gloves for the C Diff isolation. The visitor had the required mask per current policy for the pandemic protocol.

The QA RN that accompanied this surveyor on the observation verified that the visitor did not have the required PPE per the isolation protocol.

E. Review of the Infection Control Policy titled, "17.17 Transmission Based Precautions" last revised 2/12/20 revealed:
-Transmission-based precautions are to be used in addition to Standard Precautions for patients with documented or suspected infection with highly transmissible or epidemiologically-important pathogens for which additional precautions are needed to prevent transmission.
-Transmission-based precautions included: Contact precautions (including Enteric Contact Precautions) [Is used when a patient has an infectious disease that may be spread by touching either the patient or objects the patient handled, and enteric contact precautions include infectious disease that are transmitted in fecal material.]; Droplet precautions [This is used to prevent transmission of diseases spread by large respiratory droplets through coughing, sneezing or talking.]; Airborne Precautions [This is used to prevent the transmission of infectious agents that remain viable and suspended in the air over long distances.] and Neutropenic precautions [This is used to protect the patient from others germs due to the bodies compromised ability to battle infections.]
-If a patient is on transmission-based precautions, signage indicating the specific precaution is placed on the patient's door. Necessary PPE for the specific is placed in a designated at the patient's room entrance.
-All person's entering the patient's room or space are expected to comply with the transmission-based precautions and PPE requirements.
-Patients are placed in precautions via a physician order or by nursing services utilizing the reference CDC (Center for Disease Control) 2007 Guidelines for Isolation Precautions: Preventing transmission of Infectious Agents in Healthcare Settings.

F. An interview on 9/15/21 at 2:50 PM with the Facilities Manager revealed that all the rooms on the 100 wing, 200 wing and 600 wing have be converted into negative pressure rooms. The HVAC (heating-ventilation-air conditioning) technician has come to the facility to change the rooms from a positive to a negative flow. The technician utilized a vane meter that verified the airflow. This is accomplished by adjusting each room ventilation box (in the ceiling) for the air flow. The Facilities Manager was unable to identify the exact number of air exchanges each room gets. The established AIIR (Airborne Infection Isolation Rooms - is a room designed to provide 12 air exchanges per hour and vents directly outside.) The facility was constructed with 4 AIIR's (room 101, 312, 604 and the emergency room trauma bay). The Facility Manager stated that it would require a 3rd party vendor to come and test the air flow and the facility had not done that.

G. Review of the Hospital Covid-19 Plan revealed:
-The Occupational Safety and Health Administration (OSHA) issued a Covid-19 Healthcare Emergency Temporary Standard on 6/10/21, that establishes requirements to protect workers from exposure to coronavirus in all settings. The document details the (Hospital action plan) with the goal to minimize risk of transmission of Covid-19 for each employee.
-Patient Placement-Covid 19 positive patients will be placed in single-occupancy AIIR or designated negative pressure rooms.
-All Covid 19 positive patients will be care for using Covid-19 Isolation precautions, including the use of the following PPE for all patients contact: respirator (Fit tested N95 mask or PAPR (powered air purified respirator- a battery powered hood/helmet device that covers the staff's head and purifies the air they breathe.), goggles or faceshield, gown and gloves.
-place Covid-19 patients in AIIR if available.