HospitalInspections.org

Based on review of facility policy, review of facility isolation guidelines, observation, and interview, the facility failed follow infection control guidelines for 1 patient observed in isolation (#3) of 6 isolation patients observed.

The findings included:

Review of facility policy, Isolation Precautions Policy, revised on 10/6/15 revealed "...gloves and hand hygiene: perform hand hygiene...don gloves before entering the room...remove gloves before leaving the room and perform hand hygiene...after glove removal and hand hygiene, ensure that hands do not touch potentially contaminated environmental surfaces or items in a patient's room to avoid transfer or microorganisms to other patient environments..." Further review revealed "...don a clean gown before entering...remove gown and discard before leaving patient environment...hand hygiene will be performed before and after contact with the patient..."

Review of the facility's isolation guidelines, with no date, revealed "...Clostridium Difficile [C.Diff- highly contagious bacterial infection in the colon]...enteric isolation [type of isolation for patients with C Diff] precaution...handwashing with soap and water is recommended..."

Observation on 12/6/17 at 8:40 AM, at Hospital A on the 3rd Central Medical Surgical Unit, revealed Certified Nurse Assistant (CNA) #1 entered Patient #3's room. Continued observation revealed the patient's room had a sign located on the outside of the door labeled "Enteric Isolation." Further observation revealed the CNA failed to don a gown or mask and failed to wash the hands prior to entering the patient's room. Continued observation revealed the CNA exited the patient's room and without washing the hands, removed the patient's food tray from the food cart located in the hallway, and re-entered the patient's room. Further observation revealed the CNA then exited the room without washing the hands.

Observation on 12/6/17 at 8:45 AM, at Hospital A on the 3rd Central Medical Surgical Unit, revealed Registered Nurse (RN) #1 entered Patient #3's room without donning a mask or gown and without washing the hands. Further observation revealed the RN spoke with the patient and exited the room without washing the hands.

Interview with CNA #1 and RN #1 on 12/6/17 at 8:47 AM, on the 3rd Central hallway, confirmed the patient was in Enteric Isolation with a diagnosis of C.Difficile. Further interview confirmed the CNA and the RN failed to wash the hands prior to entering and exiting the room and failed to don a mask or gown.

Interview with the Nurse Manager on 12/6/17 at 8:50 AM, at Hospital A in the 3rd Central Nurses Station, confirmed the facility failed to follow infection control guidelines and the facility failed to follow facility policy.