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Based on observation and interview, the hospital failed to ensure the Infection Control Officer implemented a surveillance system for controlling infections as evidenced by:
1. failure to ensure staff wore appropriate personal protective equipment while in a patient's room who was in contact isolation for 2 (Patient #R1, #R2) out of 2 patients observed for correct isolation procedures;
2. failure to ensure contaminated patient care equipment was not removed from a patient's room who was in contact isolation for 1 (Patient #R1) of 2 patients observed for correct isolation procedures;
3. failure to ensure the glucometer was properly disinfected after use for 1 of 1 patients (#R3) observed for glucometer use.
Findings:


1. Contact Isolation

Patient #R1
Observations on 03/23/16 at 11:30 a.m. revealed the patient, who was in the medical intensive care unit, was on contact isolation precautions. Further observations at that time revealed that S15Respiratory Therapy Student and S20Teaching Assistant were in the patient's room providing respiratory care. Observation of S15Respiratory Care Student revealed that she had her personal stethoscope around her neck and the gown she was wearing was not tied around her neck allowing the gown to hang below her shoulders.

Further observations at 11:55 a.m. revealed that S15Respiratory Care Student walked to the doorway of the patient's room, wiped her stethoscope with an alcohol pad and then placed it back around her neck. She was still wearing the contaminated gown at that time. She then removed the gown and walked out of the room and down the hall with her stethoscope in her hand.

Observations on 03/23/16 at 12:00 p.m. revealed S14RN walked into the patient's room without wearing any personal protective equipment. Upon exiting the room, she was observed to walk back into the nurse's station.

S12RN Patient Care Coordinator for Critical Care (PCC-CC) was present during the above observations. She confirmed that all staff who enter the room of a patient in contact isolation should don personal protective equipment, which includes gown and gloves. She further stated that the gowns should be tied securely at the neck and staff should not remove any personal care equipment out of the room.

Review of the medical record for Patient #R1 revealed she was on contact isolation precautions due to C-Difficile infection.

Patient #R2
On 03/23/16 at 12:10 p.m., observation revealed the patient, who was in the medical intensive care, was on contact isolation precautions. Further observations revealed that S14RN walked into the patient's room without wearing any personal protective equipment. At that time, S12RN PCC-CC asked S14RN why she did not wear a gown or gloves when entering the room. S14RN held her hands up in the air and stated that she was just checking the patient's pump and that she did not touch anything in the room.

Review of the medical record for Patient #R2 revealed she was on contact isolation precautions due to C-Difficile infection.


2. Glucometer
On 03/23/16 at 11:15 a.m., observation revealed S16RN used a glucometer to check the blood glucose of patient #R3, who was in the critical care unit. Further observations at that time revealed that after using the glucometer on the patient, he wiped it with an alcohol swab and returned it to the nurses station.

On 03/23/16 at 3:15 p.m., interview with S7RN Infection Control revealed that hospital policy stated that staff are to use PDI Super Sani Cloths to clean the glucometers after use on patients. She further stated that wiping with an alcohol swab was not appropriate.