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Based on observation, medical record review, review of policies and procedures, and interview with the facility staff, the facility failed to ensure staff followed the current facility policy related to Contact isolation. This affected one patient, Patient #10 with the potential to affect all patients cared for in the Neonatal Intensive Care Unit (NICU). The current NICU census was 22.

Findings include:

A tour of the NICU was completed on 01/27/20 at 10:00 AM with Staff B, Staff C, Staff I, and Staff M. The NICU has a bed capacity of 34 with a census of 22 on this day. Portable curtains were noted at Bedside #14 around two isolettes and at Bedside #15 around an open crib where a nurse wearing gloves and a gown was holding an infant.

Interview with Staff I during the tour revealed no infants were in isolation with the last infant being isolated in early January. No isolation signs or the presence of isolation carts were observed during the tour to designate any infants were in isolation on the unit.

Interview with Staff C on 01/28/20 at 9:10 AM revealed that the NICU had two infants (twins) in isolation, which were moved to an isolation room earlier that morning. Staff C verified that these were the two infants located at Bedside #14 and #15 with the portable screens noted during the tour on 01/27/20. During the interview, Staff C was reminded that no signage was posted on the portable screens surrounding Beds #14 and #15 to indicate that the infants were in isolation. Staff C was asked how staff would know that these infants were on isolation. Staff C stated "maybe they were informed during report".

A brief tour of the NICU was completed on 01/28/20 at 6:00 PM. Two infants (Patient #10 and their twin) were observed in the isolation room with a sign outside the door stating "Contact Isolation" and an isolation cart was observed next to the entrance of the room. Interview with Staff J revealed that these infants (twins) were moved to the isolation room that morning.

Staff C was asked to provide a list of all positive cultures for the past two months. The list identified six infants, which included Patient #10 and their twin, who tested positive for Methicillin Resistant Staphylococcus Aureus (MRSA). Staff C again stated that none of these infants would need to be isolated or need signage since the cultures are not on the Enterprise Isolation Precaution Quick Guide. A copy of this guide along with the Type and Duration of Disease Specific Precautions for Adult and Pediatric Patients was provided and reviewed on 01/29/20. The Quick Guide states to use Standard precautions for all patients with MRSA. The Disease Specific Precautions states all patients with MRSA are to use Standard precautions and Contact precautions if drainage cannot be contained. This guide further stated that Contact precautions should be used for patients in the NICU who are positive for MRSA.

A request for the isolation policies was made on 01/27/20. Staff C provided the policies titled "Contact Precautions" (12/12/18) and "Droplet Precautions" (01/13/16). The Contact Precaution policy stated that these precautions will be applied to any patient with a confirmed or suspected infection of an epidemiological important pathogen that can be transferred from one person to another via direct or indirect contact. Both policies refer to the Enterprise Adult and Pediatric Hospital Isolation Guide, which again stated to place infants in the NICU in Contact Isolation if positive for MRSA. The Contact Isolation policy stated to place the patient in a private room, if no private room is available, to draw the curtain and place adequate signage to ensure all personnel are aware of the Contact Precautions.

Interview with Staff A and Staff C on 01/29/20 at 3:45 PM confirmed the findings of no signage at Bedside #14 and #15 during the tour on 01/27/20.

The NICU staffing assignments for the time period between 12/01/19 through 1/27/20 were reviewed on 01/27/20. There was no documentation on the staffing sheets that any infants were in isolation during that time frame.

The medical record of Patient #10 was reviewed on 01/29/20. Review of the medical record revealed Patient #10 was born on 12/11/19 at 1:58 PM (Twin A) at 29 weeks gestation. Nursing notes revealed the infant began to have left eye drainage on 12/21/19 at 3:00 AM. Nursing notes on 12/21/19 at 3:00 PM revealed a large amount of creamy yellow drainage was noted. The drainage was cleansed with a saline wipe. Nursing notes further revealed the drainage continued with an eye culture obtained on 12/24/19 at 1:24 AM and reported back on 12/26/19 as MRSA. There was no documentation in the medical record that the infant was placed in Contact isolation as the Contact Precaution policy and Type and Duration of Disease Specific Precautions policy instructed.

An order for contact and droplet precautions was noted in the medical record for Patient #10 on 01/08/20 after a respiratory culture was obtained. The contact and droplet precautions were discontinued on 01/09/20 when results came back as negative. The medical record revealed a positive nares culture for MRSA on 01/18/20 at 7:00 PM with an order received on 01/18/20 at 7:36 PM to place the infant on Contact isolation. The medical record was reviewed with Staff B on 01/29/20 at 1:50 PM. Nursing documentation revealed the infant was placed in isolation on 01/19/20 at 1:00 PM.

A second interview was completed with Staff C on 01/29/20 at 3:30 PM. Staff C again confirmed infants with MRSA do not need to be isolated or have signage. The facility's Type and Duration of Disease Specific Precautions, provided on 01/28/20, states that infants in the NICU who have MRSA are to be placed in Contact isolation. This policy was reviewed with Staff C.

Staff C then confirmed that this infant should have been placed in Contact isolation when the eye drainage culture came back positive for MRSA on 12/26/19.