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Based on observation, interview, and policy review the facility failed to: -Ensure staff utilized Personal Protective Equipment (PPE, gown/gloves) according to policy for one patient (#9) of one patient. Patient #9 was identified as being on contact isolation precaution (patients had been identified as having a particular organism that was especially contagious or difficult to treat. Additional protection is needed to prevent contamination of other patients or staff).
-Ensure staff placed a tube holder to anchor (prevent movement) of the urinary catheter (a sterile tube inserted into the bladder to drain urine into a drainage bag) for two (#1 and #4) of four patients with urinary catheters during observations of urinary catheter care. Tension on the urinary catheter can cause trauma to the opening of the bladder and cause infection in the bladder.
-Ensure staff washed and dried nebulizer (equipment used to produce an extremely fine spray of medication to penetrate the lungs) after each use for one (#2) of two patients receiving nebulizer treatment. Failure to clean equipment can provide a warm moist environment that encourages organisms to grow in the nebulizer equipment and can cause infection. The facility census was 83.

Findings included:

1. Record review of the facility policy titled, "Contact Precautions", revised 05/09 showed direction for facility staff to remove gown and gloves prior to leaving the patient's environment to avoid transfer of microorganisms to other patients or environments.

2. Observation on 08/21/12 at 8:00 AM showed Staff S, CNA, exited Patient #9's room without removing PPE, received additional supplies from Staff T and reentered room. The patient's room had an "Isolation" sign posted on door. The "Isolation" sign is the facility's means of alerting staff and visitors of what protective equipment requirements are needed to take care of the patient, staff and visitors e.g. gowning, gloves and hand hygiene.

3. During an interview on 08/21/12 at 8:55 AM Staff S, CNA, stated that she didn't think she went past the door jamb. Staff S stated that she knows she is not supposed to exit the room with PPE on and they are educated once a year on isolation precautions.

4. Review of Patient # 9's medical record showed patient on contact isolation for Methicillin Resistant Staph Aureus (MRSA) an organism that causes infection and is very resistant to powerful antibiotics, (medication used to fight infections).

5. During an interview on 08/21/12 at 8:45 AM, Staff T, Nursing Supervisor, stated that Staff S had forgotten some linen she needed to care for the patient and asked him to obtain it. Staff T stated staff doesn't think they are exiting the room; they are just leaning out of the doorway.

6. During an interview on 08/22/12 at 12:15 PM Staff P, Infection Control Coordinator, stated that staff should never go past the door jamb without removing PPE.

7. Record review of Perry & Potter - 7th Edition - 2010, provided by Staff FF, Quality Assurance Manager on 08/20/12, gave direction for staff to replace, as necessary, the adhesive tape or multipurpose tube holder that anchors catheter to patient's leg or abdomen. Tension causes urethral trauma.

8. Observation on 08/20/12 at 2:35 PM showed Staff G, Registered Nurse (RN), provide urinary catheter care to Patient #4. Staff G failed to anchor urinary catheter after providing care.

9. During an interview on 08/20/12 following urinary catheter care, Staff G stated that catheter should be secured to prevent infection. Staff G stated that she did not know why she failed to secure the catheter.

10. Observation on 08/20/12 at 3:25 PM showed no anchor to urinary catheter for Patient #1.

11. During an interview on 08/20/12 at 3:30 PM, Staff I, RN, stated that the family was visiting the patient (Patient #1) and she did not want to get personal with the patient. Staff I stated that "I can sure get one on". Staff I stated that the catheter should be secured so it does not get dislodged.

12. Record review of facility policy titled "Nebulized Medications Therapy", provided by the Director of Respiratory Therapy, Staff AA, on 08/21/12, showed the following direction:
- At the end of the treatment, turn off the flowmeter and empty any residual medication remaining in the nebulizer cup by unscrewing the top of the nebulizer and inverting the nebulizer to drain the liquid. A good shake will help to fully empty the nebulizer.
- Store the nebulizer set up in a plastic bag, labeled with the patient's name. The setup is changed weekly.

13. Observation of nebulizer medication treatment for Patient #2 on 08/20/12 at 3:30 PM showed Staff K, Registered Respiratory Therapist, place the nebulizer in bag after treatment. The nebulizer was not washed or dried prior to placing in patient bag.

14. During an interview on 08/21/12 at 3:30 PM, Staff AA stated that the facility does not have a policy to wash and dry the nebulizer. Staff AA stated that staff are emptying the nebulizers and allowing them to dry after they are placed in the patient's bag.



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