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Based on observations, interviews, and record reviews the facility failed to ensure staff accessed Personal Protective Equipment (PPE) in a safe manner for 3 of 3 observations in which PPE was required (Patients A, B and C).

This failure created a potential for cross contamination of infectious disease to patients and staff.

FINDINGS

POLICY

According to Transmission - Based Precautions are for patients with documented or suspected infection or colonization with highly transmissible pathogens, which additional precautions are, needed to prevent transmission. The patient's caregivers should be provided education to the patient about; isolation during the patients stay, prevention measures; (e.g., Hand hygiene and PPE use) and isolation during the patient's hospital stay. Visitors should have Isolation Precaution requirements explained to them by clinical staff.

REFERENCE

According to the Centers for Disease Control (CDC) 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings When applying Standard Precautions, an isolation gown is worn only if contact with blood or body fluid is anticipated. However, when Contact Precautions are used (i.e., to prevent transmission of an infectious agent that is not interrupted by Standard Precautions alone and that is associated with environmental contamination), donning of both gown and gloves upon room entry is indicated to address unintentional contact with contaminated environmental surfaces.
One important change is the recommendation to don the indicated personal protective equipment (gowns, gloves, and mask) upon entry into the patient's room for patients who are on Contact and/or Droplet Precautions since the nature of the interaction with the patient cannot be predicted with certainty and contaminated environmental surfaces are important sources for transmission of pathogens.

According to APIC Innovative duct tape strategy, typically, Health care workers must don personal protective equipment (PPE) before entering an isolated patient's room before any type of communication. A "Red Box" safe zone is a 3-foot square of red duct tape extending from the threshold of the door to facilitate communication.

1. The facility failed to ensure all direct patient care staff properly donned PPE when entering into the isolation environment of a patients room.

a) On 05/24/17 at 8:25 a.m., an observation was conducted which revealed Registered Nurse (RN) # 2 entered into Patient A's room to give a medication. The patient was on contact isolation precautions. RN #2 proceeded halfway into the isolation room up to the red line on the floor obtained and donned PPE. RN #2 administered the medication to the patient, walked halfway back through the room, doffed the PPE, performed hand hygiene and walked out of the last half of the patient's room.

b) On 05/24/17 at 8:05 a.m., an observation was conducted which revealed RN #3 entered halfway into Patient B's room before donning PPE, the patient was on contact isolation. RN #3 then performed hand hygiene walked up to the red line, donned PPE and provided direct patient care. When RN #3 was leaving the isolation room, s/he stopped halfway out of the room, doffed the PPE, performed hand hygiene and proceeded through the last half of the room to the commonly used hallway.

c) On 05/24/17 at 8:20 a.m., an observation was conducted which revealed RN #1 in Patient C's contact isolation room who reported s/he did not know whether to don or doff his/her PPE before entering into the patients bathroom. RN #1 reported that it was very unclear to him/her what the red line meant that was on the floor in the patients room, as well as being unclear what was considered a contaminated area versus a clear area in the isolation room.

d) An interview was conducted on 05/24/17 at 12:24 p.m. with Certified Nursing Assistant (CNA) #6 who reported s/he was trained to walk into the room perform hand hygiene, open the box on the wall where the PPE was stored which was halfway into the room with isolation precautions and don the PPE. CNA #6 reported s/he could walk up to the red tape line on the floor as it was considered a clean part of the patient's room, anything past the red line was considered contaminated and PPE was required. CNA #6 stated PPE was worn to protect the staff and other patients from germs.

e) An interview was conducted on 05/24/17 at 1:20 p.m., with RN #2 who stated PPE was used to protect patients and staff from cross contamination of germs. RN #2 reported s/he was taught the red line was inside the room as a clean area to don the PPE and wash hands. RN #2 stated s/he would rather have had the PPE outside the patient's room because it made it clear what area was considered contaminated.

f) An interview was conducted on 05/24/17 at 8:26 a.m.; with RN #3, also the charge RN who reported the red line on the patient's floor was to distinguish between clean and dirty in the patient's room. Once staff had donned PPE they were not to cross over into the clean area, yet the patient's bathroom was in the clean area. RN #3 reported in order to empty a used urinal in the bathroom the staff would have had to walk through the designated clean area to empty a contaminated urinal. S/he stated the clean zone dirty zone was very confusing and s/he thought the whole patient's room was considered contaminated. RN # 3 stated it would have been better to have the PPE donned outside of the patient's room then staff would be ready to care for the patient safely.

g) An interview was conducted on 05/24/17 at 1:34 p.m., with Director of Quality Management and Interim Infection Control Nurse #5 who reported the red line was established to provide a safe zone for the direct patient care staff to perform hand hygiene and don PPE. S/he stated the safe zone was never considered a clean zone, and was not sure if s/he was putting the direct patient care staff at risk by having the safe zone in the room. S/he further reported the bathroom located in the safe zone was considered a contaminated area because dirty laundry was stored there as well as Foley bags and used urinals were emptied in the bathroom. S/he stated that staff understood the safe zone was an area to have access to wash their hands, and don and doff PPE.