HospitalInspections.org

Based on document reviews, and staff interview, it was determined that for 1 of 5 (Pt #1) clinical records reviewed with a positive MRSA (Methicillin Resistant Staphylococcus Aureus) screen, the hospital failed to patient did not acquire MRSA while hospitalised ensure contact isolation was initiated in a timely manner as required by Hospital practice and policy.

Findings include:

1. The Hospital policy titled, " Methicillin resistant Staphylococcus Aureus Screening for the NICU,"
(originated 4/18/08) reviewed on 4/16/13 required, "...all NICU infants will be screened for MRSA upon admission and every Monday... Polymerase Chain Reaction (PCR) -Laboratory technique used for raid identification of bacteria through genetic testing... Precaution/isolation: ...PCR positive: a. contact Isolation.

2. The clinical record of Pt. #1 was reviewed on 4/16/13. Pt. #1 was admitted to the Neonatal Intensive Care Unit (NICU) at birth on 2/8/13 for monitoring for withdrawal due to maternal history of heroin use treated with Methodone. Laboratory results for MRSA (Methicillin Resistant Staphylococcus Aureus) screen from the nares on 2/8/13 and 2/11/13 were negative, however on 2/18/13 MRSA was PCR positive. The clinical record included a physician order dated 2/18/13 for "contact isolation". However, the record lacked documentation of contact isolation being initiated timely, with the first isolation documentation beginning on 2/21/13, 3 days after the order for isolation was written.

3. The above findings were confirmed with the Nurse Manager on 4/17/13 at approximately 2:00 PM, who stated isolation should have been documented beginning on 2/18/13.