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Based on interview and record review, the hospital failed to follow its infection control policy when one out of ten sampled patients (Patient 3) had their isolation precautions (steps taken to prevent the spread of germs in healthcare and residential settings) discontinued when they continued to be at risk for spreading Clostridium Difficile (C. diff, a highly contagious bacteria that causes diarrhea and other intestinal issues and is spread through contact with contaminated surfaces, hands, or equipment).

This failure has the potential for the spread of C. diff to other patients or hospital staff due to the lack of appropriate precautions and protections.

Findings:

A review of a critical care progress note, dated 01/04/25, indicated that Patient 3 was admitted in October of 2024 and has a complex medical history including a cardiac arrest (when the heart suddenly stops working), end stage renal disease (ESRD, a permanent condition that occurs when the kidneys can no longer function and require dialysis or a kidney transplant to survive), respiratory failure (when the lungs don't work properly), and septic shock (a life-threatening condition that occurs when an infection overwhelms the body causing dangerously low blood pressure).

A review of a Patient 3's medical record overview, screenshot provided by facility on 01/15/25, indicated a section titled "Patient Isolation Status". The overview section indicated that Patient 3 was placed on "Enteric Contact" isolation (a set of procedures that prevent the spread of infection from a person who has a gastrointestinal illness) on 12/27/24 and was subsequently removed from isolation on 01/04/25 for an undocumented reason.

A review of Patient 3's Stool Assessment/Output Flowsheet (a form that gathers all the important data regarding a patient's condition), dated 01/03/25, indicated that Patient 3 had 200 milliliters (mL, a metric unit of measurement used to quantify an amount of liquid) of stool at 6:00 PM that was described as "loose" and "watery". This measurement came from a "rectal tube" (a flexible tube inserted into the rectum that can help drain stool).

A review of Patient 3's Stool Assessment/Output Flowsheet, dated 01/04/25, indicated that Patient 3 had an unmeasured amount of stool at 11:00 AM and 4:00PM that was described as "loose" and "watery". Both episodes of stool came from a "rectal tube".

A review of Patient 3's Stool Assessment/Output Flowsheet, dated 01/05/25, indicated that Patient 3 had an unmeasured amount of stool at 8:00 AM that was described as "loose; watery" and 80mL of stool at 5:00 PM that was described as "watery". Both episodes of stool came from a "rectal tube".

A review of Patient 3's Stool Assessment/Output Flowsheet, dated 01/06/25, indicated that Patient 3 had an unmeasured amount of stool at 12:00 AM that was described as "watery" and "loose", 100mL of stool 6:30 AM that was described as "watery", and an unmeasured amount of stool at 8:00PM that was described as "watery" and "loose". All three episodes of stool came from a "rectal tube".

A review of Patient 3's Stool Assessment/Output Flowsheet, dated 01/07/25, indicated that Patient 3 had 50mL of stool at 7:00 AM that was described as "watery" and an unmeasured amount of stool at 8:00 AM that was described as "watery" and "seedy" (loose stool that has a texture similar to seeds). Both episodes of stool came from a "rectal tube".

During a concurrent interview and record review on 01/14/25 at 2:21 PM with the interim-infection prevention manager (IPM), Patient 3's Stool Assessment/Output Flowsheet, dated 01/04/24 to 01/07/25, was reviewed. The flowsheet indicated that Patient 3 had multiple episodes of "loose" and "watery" stools while their enteric isolation precaution was discontinued. The IPM stated that Patient 3 should have been continued on enteric isolation as they continued to be symptomatic.

A review of Patient 3's laboratory report titled "Clostridioides difficile Toxigenic PCR with Reflex to Toxin Immunoassay" (a laboratory test for C. diff), dated 01/07/25, indicated that Patient 3's stool tested positive for the C. diff toxin gene (specific segment of genetic instructions for making a C. diff toxin protein) and negative for C. Diff toxin protein. The report further indicated, "Correlate with clinical information. Contact Infectious Disease for help with interpretation and management ...Enteric Contact Isolation required"

During an interview on 01/15/2025 at 2:14 PM with an Infection Preventionist (IP), the IP was stated that upon additional review of Patient 3's clinical record, there continued to not be a clinical rationale documented as to why enteric isolation was discontinued on 01/04/25.

A review of facility guidelines titled, "UCSF ADULT POPULATION: CLOSTRIDIOIDES DIFFICILE (C. DIFF) PREVENTION GUIDELINES", dated 08/22/23, indicated that "Enteric Contact Isolation can be discontinued when: 1. Diarrhea resolves with discontinuation of laxatives/stool softeners or adjustment of tube feeds and there is no suspicion for an infection. 2. C. difficile test result is negative ...and no alternative diarrheal infection is suspected. 3. C. difficile test result is gene ...positive/toxin protein negative AND diarrhea absent for >/= [greater than or equal to] 48 hours AND a new clean room is available ..." The guidelines further indicated that "If your patient's C. difficile test is negative, continue enteric contact isolation IF you still suspect an alternative infectious source of diarrhea. C. difficile is not the only organism that can spread in the hospital. If you are concerned that another infection is responsible for your patient's diarrhea, then continue enteric isolation and consider diagnostic testing for other infections. 2. If your patient is C. difficile toxin gene positive/protein negative and having diarrhea, then continue enteric contact isolation. Although colonized [has the bacteria but not actively infected] patients may have an alternative explanation for their diarrhea, they may still transmit spores into the environment while having diarrhea, which can subsequently infect other vulnerable patients ..."