HospitalInspections.org

Based on interview, record review, video review and a review of facility policy, the facility failed to ensure that policies governing control of infections in the form of required gowning for patients on contact isolation were followed with one of ten sampled patients. (#1)

Findings:

A review of the medical record of patient #1 was performed. A lab report of 4/26/15 at 3:32 AM read: "Final report: Methicillin Resistant Staphylococcus aureus (MRSA) isolated." Physician orders of 4/30/15 read: "Tube feed adult - intermittent - Jevity ... Enteral tube (Dobhoff) ... Nocturnal TFs (tube feeds) from 8 PM - 8 AM." A nurse's note of 5/5/15 at 7:28 PM read: "Isolation precautions: Contact - MRSA."

A review of video of the patient, in bed, made with a facility-installed camera used for fall prevention, was performed with the Risk Manager on 6/18/15 at approximately 9:30 AM. The period in the video covered from 10:30 PM to 11:00 PM on 5/5/15. In the video, the son of the patient was seen feeding the mother. He eventually left before the nurse, began activities regarding the feeding tube after having entered the room at the lower right of the screen. She had a disposable gown and gloves on, but the gown was not tied in back and hung loosely. The gown remained in this form for the duration of the nurse's stay. The nurse hung the Jevity on the pump, which was at the head of the bed at the patient's left. Once having completed the set up of the pump and other patient care activities, the nurse was observed in the lower right corner of the screen removing the gown. While the gown was off, she went back to the patient's bedside, gave the patient her call light and touched her right arm with her gloved hand. During these activities, the nurse was seen leaning against the patient's right side bed rail, with her uniform, now without a gown covering.

A review of facility policy "Transmission-Based Isolation Precautions" revealed the following: "All patients with certain known or suspected infectious disease/infections are placed on transmission-based isolation precautions as recommended in this policy ... Wear a gown if your clothing or skin comes in contact with blood, body fluids, contaminated items or surfaces." Thus, the nurse broke protocol with respect to the prevention of potential disease transmission, to other patients, through improper wearing of the gown and having removed it so that it exposed her clothing to a potentially contaminated surface in the form of a bedrail. Regarding the gown issues, during an interview of the nurse on 6/18/15 at 12:54 PM, she stated that she was not aware that the gown was not being worn in a proper manner. She did not remember contacting the bedrail without the gown on.

During an interview of the Risk Manager on 6/18/15 at approximately 4:15 PM, she confirmed the preceding.