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Based on observation, interview and record review, the hospital failed to ensure an effective infection prevention and control program that provides consistent information and instruction to visitors regarding infection control to help visitors understand the risks of spreading disease and the benefits of following isolation measures for five of seven patients sampled (Patient 1, 2, 3, 4, & 5) who were in contact isolation precautions that included diagnoses of Clostridium difficile (C. Diff), Methicillin-resistant staphylococcus aureus (MRSA) or Vancomycin-resistant enterococci (VRE).

This deficient practice resulted in the transmission of an infectious disease to a visitor and has the potential to place all patients, visitors, and staff at risk for the transmission of infections.

Findings Include:

Review of the hospital's policy titled, "Standard and Transmission Based Isolation Precautions" dated 04/2019, identified the following: "Implementing Isolation precautions: Patients should be placed in isolation for known or suspected infections or organisms based on Centers for Disease Control (CDC) Isolation Guidelines. Visitors may be offered PPE [Personal Protective Equipment] upon request but cannot be required to wear it. Visitors should be provided information to help them understand the risks of spreading a disease and the benefits of following isolation measures."


Review of Patient 1's "History and Physical" dated 04/19/19 revealed that she was admitted on 04/19/19 and discharged on 05/02/19 with diagnosis of abdominal pain of one-week duration, associated with nausea as well as diarrhea. Review of Patient 1's laboratory results dated 04/20/19 indicated C. Diff for feces, no growth, positive.

On 06/11/19 at 08:34 AM telephone interview with Patient 1's Friend 8 (F8), stated, "she was visiting a friend (Patient 1) in the hospital and noticed a precaution sign on the door. She went to the nurses' station and asked what she needed to do, and she was told don't worry, that is for the nurses. She helped her friend to the bathroom and before she left her friend told her she had C. Diff. Caller stated that she began having GI symptoms and was checked by a Personal Care Physician and her stool came back positive for C. Diff and she was treated with antibiotics. She called the patient representative at the hospital ... Her daughter also began having GI symptoms and was treated empirically with antibiotics." Friend 8 identified speaking to Staff O, Nurse Manager and a Patient Advocate, and stated, I should have been educated on what she (Patient 1) had. Friend 8 stated that Staff O, Nurse Manager stated that they would do better with signage." Friend 8 stated, "the sign on the door did not include to wear gown or gloves" when entering the room.

During a tour of the hospital on 06/10/19 starting at 3:00 PM and on 06/11/19 beginning at 10:30 AM, employees were interviewed regarding their understanding of the infection control program at the hospital, training, reporting procedures, methods to reduce transmission of infection, and use of PPE. Three of 14 Nurses/Nurse Assistants revealed that wearing PPE was for employees or anyone going into different patient rooms (Staff P, Registered Nurse (RN), Staff Q, RN, and Staff T, RN).

During interviews with employees related to visitors following contact precaution signs located on the door or cart in front of the patients' rooms showed inconsistent answers including:
"Educate family members, not mandatory for family to wear gown, gloves/follow procedure on door." Educate them on why, can't force them to don the proper PPE." "Contact precaution sign is for staff and for visitors so that they are aware." "I don't think visitors have to wear a gown and gloves unless they are going into another patients' rooms." and "Do not require visitors to gown up; we put reminders on Purell (hand sanitizer) to wash hands."

During patient and family interviews, the following responses were related to the use of PPE included: "her niece was told she didn't have to (wear a gown or gloves), as she wasn't interacting with other patients." and "they did not tell me why they were wearing gown/gloves; precautionary measure. They did not tell me about wearing gown, gloves. I have not been given instructions.

Refer to A-0749

Based on observation, interview and record review, the hospital failed to provide infection control practices regarding personal protective equipment (PPE) for visitors of five of seven patients sampled (Patient 1, Patient 2, Patient 3, Patient 4 and Patient 5) that had contact isolation precautions that included diagnoses of Clostridium difficile (C. Diff), Methicillin-resistant staphylococcus aureus (MRSA) or Vancomycin-resistant enterococci (VRE).

Findings Include:

Review of the hospital's training titled, "2019 Annuals-Safety-Patient" indicated, "Transmission Based Isolation Precautions, Contact - Defined: germs are transmitted by direct or indirect contact. Protection - PPE: gown and gloves. Examples: Antibiotic-resistant bacteria like MRSA or VRE."

Review of the hospital's policy titled, "Standard and Transmission Based isolation Precautions" dated 04/2019, identified the following: "Implementing Isolation precautions: Patients should be placed in isolation for known or suspected infections or organisms based on Centers for Disease Control (CDC) Isolation Guidelines. Visitors may be offered PPE upon request but cannot be required to wear it. Visitors should be provided information to help them understand the risks of spreading a disease and the benefits of following isolation measures."

Review of the hospital's undated policy titled, "The University of Kansas Health System Transmission Based Precautions: Contact" indicated, "How to use contact precautions: Have family members and other visitors wear a gown and gloves as outlined by your facility."

Review of the document "The Clostridium Difficile (C. Diff)" a two-page list of "material to help you understand what c. diff is and how to prevent the spread of C. Diff", dated 06/17 indicated "Approved by the Patient Education Committee" identified procedures for how visitors can prevent the spread of C. Diff: Visitors should wash their hands with gel sanitizer or soap and water before entering your room. Visitors should wash their hands with soap and water when leaving your room."


Review of Patient 1's "History and Physical" dated 04/19/19 revealed that she was admitted on 04/19/19 and discharged on 05/02/19 with diagnosis of abdominal pain of one-week duration, associated with nausea as well as diarrhea.

Patient 1's care plan included, "will treat patient empirically with IV [intravenous] Rocephin 1 g [gram], IV metronidazole 500 mg 3 [three] times daily for possible infectious gastroenteritis."

Review of Patient 1's laboratory results dated 04/20/19 indicated C. Diff for feces, no growth, positive.

Review of the "Complaint Intake" dated 05/06/19 and the 06/11/19 at 08:34 AM telephone interview with Patient 1's Friend 8 (F8), stated, "she was visiting a friend (Patient 1) in the hospital and noticed a precaution sign on the door. She went to the nurses' station and asked what she needed to do, and she was told don't worry, that is for the nurses. She helped her friend to the bathroom and before she left her friend told her she had C. Diff . Caller stated that she began having GI symptoms and was checked by a Personal Care Physician and her stool came back positive for C. Diff and she was treated with antibiotics. She called the patient representative at the hospital ... Her daughter also began having GI symptoms and was treated empirically with antibiotics." Friend 8 identified speaking to Staff O, Nurse Manager and a Patient Advocate, and stated, I should have been educated on what she (Patient 1) had. Friend 8 stated that Staff O, Nurse Manager stated that they would do better with signage." Friend 8 stated, "the sign on the door did not include to wear gown or gloves" when entering the room.

During a tour of the hospital on 06/10/19 starting at 3:00 PM and on 06/11/19 beginning at 10:30 AM, employees were interviewed regarding their understanding of the infection control program at the hospital, training, reporting procedures, methods to reduce transmission of infection, and use of PPE. Three of 14 Nurses/Nurse Assistants revealed that wearing PPE was for employees or anyone going into different patient rooms (Staff P, Registered Nurse (RN), Staff Q, RN, and Staff T, RN).

Below are excerpts of responses from employees related to visitors following contact precaution signs located on the door or cart in front of the patients' rooms:


a. On 06/10/19 at 03:35 PM interview with Staff D, Registered Nurse (RN), stated, "educate family members, not mandatory for family to wear gown, gloves/follow procedure on door." Educate them on why, can't force them to don the proper PPE."

b. On 06/10/19 at 04:10 PM interview with Staff F, RN, stated, "advise family, if they wish to don PPE, welcome to (the PPE); all we can do is educate; have conversation with patient and family regarding isolation."

c. On 06/10/19 at 04:40 PM interview with Staff H, RN, stated "if they have MRSA, don PPE, let family know; make sure washing hands. Teaching in a way they understand."

d. On 06/10/19 at 06:10 PM interview with Staff K, RN, stated, "Educate family; if they ask why wearing a gown, I will explain and suggest that they use a gown; can't force them to wear a gown." Staff K stated, "there is a husband and daughter that visit, don't gown up and they have been informed."

e. On 06/11/19 at 12:05 PM interview with Staff P, RN, stated, "contact precaution sign is for staff and for visitors so that they are aware."

f. On 06/11/19 at 12:11 PM interview with Staff Q, RN, stated, "I don't think visitors have to wear a gown and gloves unless they are going into another patients' rooms."

g. On 06/11/19 at 02:50 PM interview with Staff T, RN, stated, "do not require visitors to gown up; we put reminders on Purell (hand sanitizer) to wash hands."


During patient and family interviews, the following responses were related to the use of PPE:

a. On 06/11/19 at 11:10 AM interview with Patient 2, stated, "her niece was told she didn't have to (wear a gown or gloves), as she wasn't interacting with other patients."

b. On 06/11/19 at 11:25 AM interview with Patient 3, stated, "they didn't have my wife gown up last night, which was the last time she visited."

c. On 06/11/19 at 11:40 AM interview with Patient 4, stated, "visitors are unsure of what is required (gown, gloves). A friend from work visited yesterday and didn't wear (protective garments); hit and miss with family wearing (protective) attire."

d. On 06/11/19 at 03:10 PM interview with Patient 5's Family 10 (F10), stated "she (staff) said I didn't need to gown up, because I wasn't going to other patient rooms - good handwashing." Patient 5 stated, "the nurses wear gowns and gloves, so they don't spread (infection) to other patients."

e. On 06/11/19 at 07:05 PM telephone interview with Patient 3's wife (F11), stated, "they did not tell me why they were wearing gown/gloves; precautionary measure. They did not tell me about wearing gown, gloves. I have not been given instructions. I know wash, wash, wash (hands)."

f. On 06/11/19 at 07:15 PM telephone interview with Patient 2's niece (F12) stated, "They didn't ask me to wear a gown. I'm currently receiving chemotherapy. When I knew she had an infection, I put on a gown."

g. On 06/11/19 at 07:25 PM telephone interview with Patient 6, discharged patient previously diagnosed with C. Diff, stated, "they (staff) didn't ask them (family members) to wear a gown when they visited." When asked who visited, she stated, "daughters, husband, father, and sister." She stated, "they informed her family the reason staff wore gown and gloves, was because I had an infection."


Interviews with supervisors regarding statements from the Nursing staff, patients and visitors included the following:

a. On 06/11/19 at 11:30 AM interview with Staff O, Nurse Manager, stated, "I will follow-up; we do (annual) training and orientation. Staff have access to visitor guideline and use Krames (resources) for patient education."

b. On 06/11/19 at 11:45 AM continued interview with Staff O, Nurse Manager, revealed they need to do more education regarding visitor guidelines, offer PPE.

c. On 06/11/19 at 12:05 PM interview with Staff O, Nurse Manager, during the interview with Staff P, RN, stated, "we should at least offer and educate; explain benefit and risks."

d. On 06/11/19 at 12:55 PM telephone interview with Staff S, Infection Control Nurse, when asked about the hospital's policy titled, "Standard and Transmission Based isolation Precautions" dated 04/2019, that identified "Visitors may be offered PPE upon request, but cannot be required to wear it," she stated, "the intent is to perform that precaution and make the recommendation that they (visitor) wear the PPE. It (PPE) is always available, a cart with PPE supplies is in front of the patient's room."

Review of the "UHC [University Hospital Committee] Safety Intelligence: Complaints Manager Form" regarding F8's complaint, revealed that the complaint was received and opened on 04/29/19, and closed on 05/03/19. The summary indicated, "visitor concerned with exposure to C. Diff, clerk told her she did not need to gown and glove to visit patient. On 05/03 pt [patient] contacted rep [representative], she had followed up with her PCP [Primary Care Physician] and was now testing positive for C. Diff." On 05/03/19 the patient relations representative responded to a call from F8 which documented, "take a look at isolation signage. We cannot require visitors to gown and glove, but we did discuss that we would make it a point to encourage it." The UHC report dated 05/03/19 indicated, Staff O, Nurse Manager, "proposed that infection control come up with a visitor guidelines sheet that can be placed on the door of any patient in isolation. She was going to take back to Staff S, Infection Control Nurse, in infection control (department), to discuss and have them potentially create. I have already done education with the team on encouraging visitors to gown and glove if they are visiting someone with C. Diff. Since our patient education policy doesn't require visitors to wear the PPE, it is hard to enforce visitors to wear it, but we can encourage it and also stress importance of washing with soap and water and leaving personal belongings in purses and pockets."

On 06/11/19 at 02:15 PM telephone interview with Staff F, Infection Control Nurse, for further explanation to her 05/03/19 electronic (email) response to the patient relations representative as noted on the "Complaints Manager Form" dated 04/29/19, she stated, "I ...proposed that infection control come up with visitor guidelines sheet that can be placed on the door of any patient in isolation." Staff F, Infection Control Nurse stated, "We walked through the possibility of making one sheet, small brochure to give more information to visitors who come to visit patients."