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A. Based on document review and interview, it was determined that for 2 ( Pt. #4 and Pt. #5) of 9 patients reviewed for isolation precautions the Hospital failed to ensure that isolation precautions were maintained as per the policy.

Findings include:

1. On 04/03/19 at approximately 8:45 AM, the Hospital document titled, "NICU (Neonatal Intensive Care Unit) RSV (Rspiraotry Synctial Virus), Flu (Influenza), MRSA (Methicillin Resistant Staphylococcus Aoureus) List" (01/01/19 - 03/31/19) was reviewed. There were a total of two infants in the list positive for RSV that were Hospital Acquired Infections. Both the infants (Pt. #4, Pt. #5) were selected from the list for review.

2. The clinical record for Pt #4 was reviewed on 04/03/19 at approximately 9:00 AM. Pt #4 was a 2 day old boy who was admitted to the NICU on 02/08/19 with a diagnosis of prematurity and Pt #4 was discharged home on 03/07/19.

- The history and physical documentation dated 02/08/19 at 4:23 AM included, " ...Problems: 1. Prematurity: Baby born with estimated GA (gestational age) of 35 - 36 weeks. Born via vaginal delivery ...2. Risk for Infection: Baby born with an estimated GA (gestational age) of 35 -36 weeks, mother with no prenatal care. Started on Ampicillin and Gentamicin on DOL (02/05/19) (day of life) 0 (zero). Blood culture negative for 24 hours (02/06/19) ..."

- The nursing vital signs notes dated 02/08/19 at 3:00 AM included, "Respiration rate - 61-80 (normal 30-60); retractions - mild; grunting - none; color - pink; air entry - clear; total score - 2 (indicates mild respiratory distress)."

- The physician's progress notes dated 02/18/19 at 12:17 AM included, "Infant had episodes of desaturations (lack of oxygen in blood) and bradycardia (decreased heart rate) at which point sepsis (infection) and respiratory virus work up was initiated ..."

- The nursing progress notes dated 02/18/19 at 1:46 AM included, "Infant's axillary temperature was 97.4 F (Fahrenheit) (Normal 98.4 - 99.0) after warming interventions. Placed infant in pre-warmed isolette ..."

- The physician's order dated 02/18/19 at 11:34 AM included, "Respiratory Virus Panel." On 02/19/19 at 12:09 PM included, "Stat (immediate) Droplet Isolation Precautions."

- The nursing flow sheet on isolation status dated 02/18/19 indicated that the Infant (Pt. #4) was not placed on isolation precautions from 02/19/19 - 12:09 PM - 02/19/19 -5:00 PM. Total duration lapsed 4 hours 51 minutes.

- The laboratory report dated 02/19/19 at 2:45 PM included, "Respiratory syncytial virus (RSV) detected."

3. The clinical record for Pt #5 was reviewed on 04/03/19 at approximately 10:30 AM. Pt #5 was a 1 hour old newborn boy who was admitted to the NICU on 10/13/18 with a diagnosis of extreme prematurity and Pt #5 was discharged home on 03/14/19.

- The history and physical dated 10/13/18 included, "VLBW (very low birth weight) male born at 23.3 weeks GA (gestational age) ...baby is at risk for complications of extreme prematurity and therefore will need NICU care ..."

- The nursing progress notes dated 02/17/19 at 4:17 PM included, "Received baby on nasal cannula 1L (one liter) oxygen flow via blender. Baby has shallow breathing and brief episodes of desaturations ...oronasal (oral and nasal) suctioning done, obtained large to moderate whitish thick secretions, baby's cough worsening ...Respiratory culture virus and blood culture sent to lab (laboratory)."

- The physician laboratory order dated 02/17/19 at 11:05 AM included, "Respiratory Virus Panel Stat." On 02/17/19 at 11:30 AM included, "Stat Droplet Isolation Precautions."

- The laboratory report dated 02/17/19 at 8:16 PM included, "Respiratory Syncytial virus (RSV) detected."

- The nursing flow sheet notes on isolation status documentation dated 02/17/19 indicated that, the Infant (Pt. #5) was not on droplet isolation precautions from 02/17/19 - 11:30 AM - 02/17/19 -11:00 PM. Total duration lapsed 11 hours and 30 minutes.

4. On 04/03/19 at approximately 10:30 AM, the Hospital policy titled, "NICU - High Risk Nursery" dated 03/23/18 was reviewed. The policy included, "Policy: All personnel must adhere to the Infection Control Guidelines in Neonatal Intensive Care Unit. B. Place infants for RSV on Contact Precautions. G. Patients discharged home from the NICU should not be readmitted to the NICU during RSV season."

5. On 04/02/19 at approximately 11:45 AM, an interview was conducted with the Infection Control Director (MD #1) and Nurse Epidemiologist (E #4). MD #1 stated, "During the epidemiological season, when they order the respiratory panel laboratory work up, automatically the isolation precautions is fired, system generates notes indicating to place the patient on droplet precautions." E #4 stated, "I am not sure why the automatic isolation precaution was not generated for these two RSV cases. Probably, there was a glitch in the system. I (E #4) was not made aware of these two RSV cases, when they placed the order for the RSV panel. If I had known, then I would have placed the isolation precautions order by myself."

6. On 04/03/19 at approximately 10:00 AM, an interview was conducted with the RN- NICU (E #8). E #8 stated, "Sometimes the Physician will order the isolation precautions right away. In this case (Pt. #4), there was no Physician's order to place the patient (Pt. #4) on droplet isolation precautions. If we are not following the contact isolation precautions for RSV then it could spread."





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B. Based on observation, interview and document review, it was deterimined that the Hospital failed to ensure the handling and processing of clean and dirty linen as required. This has the potential to affect 301 patients on census as of 04/02/19.

Findings include:

1. On 4/2/19 from 10:30 AM to 11:50 AM, an observational tour was conducted in the linen department. In the linen room, on top of one of the clean linen cabinets there was a clear bag partially open that contained multiple dirty laboratory coats that had visible debris.

2. On 4/2/19 at approximately 11:52 AM, the Linen Technician (Z #2) was interviewed. Z #2 stated that the laboratory coats were dirty and needed to be sent for cleaning.

3. On 4/3/19 at approximately 10:00 AM, the Hospital's policy titled "Linen Services and Infection Control Standards" (approval 6/1/17) was reviewed and included "...5...The clean linen is kept in separate room labeled as the 'Clean Utility Room'. Soiled linen and clean linen shall never come in contact with each other and are always kept in separate areas..."

4. On 4/3/19 at approximately 2:43 PM, the Hospital'solicy titled "Standard and Transmission Based Precautions" (rev. 1/2018) was reviewed and included "...2. Soiled linen should be...placed directly into a laundry bag. The linen bag should be tied...and taken to the utility room..."


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C. Based on documentation review, observation and interview, it was determined that for 1 of 1 Certified Registered Nurse Anesthetist student (Z #3) in OR (Operating Room) #12 and 1 of 1 Surgeon (MD #4) in OR #18, the Hospital failed to ensure that exposed hair was completely confined in the surgical head covering.

Findings include:

1. On 4/4/19, the Hospital's policy titled "Surgical Scrub Attire Policy" (March 13, 2017) was reviewed and required "...The following infection control practices must be strictly followed...All personnel should cover their head and facial hair when in the semi-restricted and restricted areas..."

2. On 4/4/19 at 9:20 AM, it was noted that the Certified Registered Nurse Anesthetist student (Z #3) was observed in OR #12 with hair that was not confined to the surgical head covering.

3. On 4/4/19 at 9:25 AM, it was noted that the Surgeon (MD #4) was observed in OR #18 with hair that was not confined to the surgical head covering.

4. On 4/4/19 at 9:35 AM, an interview was conducted with the Director of Perioperative Services (E #13). E #13 stated that hair should be contained in the head covering and not exposed.