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Based on observation, review of facility documents and staff interview (EMP), it was determined that the facility failed to follow their established policy regarding washing hands following contact with a patient on contact isolation precautions (MR6).

Findings include:

Review on March 20, 2012, of the facility's "Isolation Precautions Policy and Procedure," last reviewed August 2011, revealed "To minimize and control the transmission of infections to patients, visitors and staff through appropriate patient placement and precautions. ... 2. Transmission Based categories ... C. Contact 1) Transmission occurs by direct body surface-to-body surface contact and physical transfer of the microorganism between a susceptible host and an infected or colonized person, or involves contact of a susceptible host with a contaminated intermediate object, usually inanimate. ... '

Observation on March 20, 2012, revealed a Contact Precaution stop sign posted on the outside of MR6's door instructing staff and visitors to "Reminder: Hand hygiene [washing hands or utilization of a foam or liquid hand sanitizer] must be performed before entering the room and following removal of PPE [Personal Protective Equipment] and leaving the patient's room. Use hand hygiene agent to clean hands prior to entering and after leaving patient room."

Observation on March 20, 2012, at approximately 10:00 AM revealed MR6's nurse call bell was ringing. Further observation revealed EMP11 and EMP12 enter MR6's room without performing hand hygiene. These employees touched the privacy curtain, the bed side rails and turned off MR6's nurse call bell. EMP11 and EMP12 then left this patient's room without performing hand hygiene. EMP11 proceeded to go to another patient room and EMP12 went to the nursing station. EMP11 and EMP12 did not perform hand hygiene following contact with MR6's environment.

Interview with EMP10 confirmed MR6 was on Contact Precautions; the sign posted on the entrance to this patient's room clearly instructed staff and visitors to perform hand hygiene when entering and leaving the room; EMP11 and EMP12 responded to MR6's ringing nurse call bell; and EMP11 and EMP12 did not perform hand hygiene following contact with MR6's environment.