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Based on observation, interview and record review, the facility failed to ensure staff followed isolation precautions (actions implemented in addition to standard precautions that are based upon the means of transmission for the infectious agent in order to prevent or control infections) when:

1. a speech therapist (ST) did not disinfect two plastic containers when leaving a contact isolation room (isolation precaution which infection can spread though contact with patient or surfaces contaminated by the patient), contaminated their hands with the containers and then handed wound care supplies to a wound care nurse who was performing wound care.

2. Registered Nurse 1 (RN 1) performed a blood draw (collection of blood from a vein using a needle) without wearing gloves and subsequently reached into an equipment cart to obtain a syringe without performing hand hygiene.

These failures had the potential to spread infection through contaminated patient care equipment potentially leading to death.

Findings:

1. A review of Patient 22's physicians order titled, "View Order Detail," undated, indicated Patient 22 had an order for "Contact Precautions Continuous" started on 3/31/25.

During an observation on 4/7/25, at 11:29 a.m., ST was in Patient 22's room performing a swallow evaluation. ST had a plastic container, with food items inside, set on a table in the room. A sign at Patient 22's room indicated Patient 22 was on contact precautions.

A review of Patient 23's wound care note titled, "Care Assessments Wound Assessment," dated 4/7/25, indicated Patient 23 had three pressure injuries on the right lower extremities and a pressure injury to the sacrum and had wound dressings changed on 4/7/25.

During an observation on 4/7/25, at 11:49 a.m., as ST was preparing to leave Patient 22's room, ST placed the plastic container on the lid of a linen basket for Patient 22's room. After doffing their personal protective equipment and performing hand hygiene, ST picked up the container and without sanitizing the container, went to the nurses station. ST placed the container on the table next to a computer and began to document care.

During an observation on 4/7/25, at 11:58 a.m., while at the nurses station, a wound care nurse asked ST to bring a wound care dressing to Patient 23's room. Without performing hand hygiene, ST reached into a bin containing wound care equipment and procured a wound care dressing for the wound care nurse. Patient 23's doorway did not indicate Patient 23 was on any isolation precautions.

During an interview on 4/7/25, at 12:10 p.m. with ST, ST stated Patient 22 was on contact precautions for vancomycin resistant enterococcus (VRE). ST stated they had performed hand hygiene but didn't wipe the plastic containers with anything. ST stated they did not perform hand hygiene between leaving Patient 22's room and handing the wound care nurse the wound care dressing. ST stated it would be expected to wipe the container after leaving a contact precaution room to prevent contamination and spread of infection.

During an interview on 4/8/25, at 3:10 p.m., with Nursing Manager (NM), NM stated Patient 22 was on contact isolation for VRE due to a history of a positive VRE lab test. NM stated facility practice was to place patients with a history of VRE on contact precautions even if current lab tests did not detect VRE.

2. A record review of Patient 21's emergency department provider note titled, "Emergency Department Note," dated 4/7/25, indicated Patient 21 was in the emergency department for gastrointestinal bleeding (bleeding in the gastrointestinal tract) and weakness. The provider note indicated Patient 21 needed to have a type and screen lab draw (a blood test to determine blood type compatibility for potential blood transfusion).

During a record review of Patient 21's laboratory results titled, "Diagnostics, Blood Bank Tests," dated 4/7/25, indicated Patient 21 had a type and screen lab drawn on 4/7/25, at 1:30 p.m.

During a concurrent observation and interview on 4/7/25, at 1:28 p.m., with Infection Preventionist (IP), RN 1 was at Patient 21's bedside performing a blood draw. RN 1 was drawing blood from the intravenous catheter (device placed directly in the vein for blood access) without wearing gloves. IP stated staff were expected to follow standard precautions and needed to wear gloves while drawing blood. RN 1 finished drawing blood with one syringe and then, without performing hand hygiene and still without gloves, reached into an equipment cart and obtained another syringe to draw additional blood from Patient 21.

During an interview on 4/7/25, at 1:30 p.m., with RN 1, RN 1 stated staff were expected to wear gloves when drawing blood, and perform hand hygiene before moving on to another task.

During an interview on 4/8/25, at 10:10 a.m., with IP, IP stated breaks in infection control such as not wearing gloves or failure to sanitize equipment had the potential for infection spread to other patients.

A review of facility policy and procedure (P&P) titled, "Isolation Precautions (Transmission Based Precautions)," dated 1/2025, indicated the policy purpose was to "prevent spread of infection through prompt initiation of infection control measures ...prevent transmission of infections between patients ...all patients will be treated according to Standard Precautions at all times ...standard precautions apply to: A. Blood ...gloves should be donned whenever there is a possibility of contact with patient's blood ...this protects both the patient and the healthcare workers...hand hygiene should be practiced before donning a pair of gloves." The P&P further indicated, "Contact precautions ...these precautions are used to reduce risk of transmission of resistant microorganisms by direct or indirect contact with a patient and/or patient's environment ...examples of these organisms are multiple drug-resistant organisms such as ...VRE ...if using common equipment or items, then adequately clean and disinfect them before use for another patient."