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Based on observation, interview, and document review, the facility failed to ensure staff followed infection control measures for one of ten patients (P7) reviewed when staff provided direct patient care to a patient on contact precautions without using the required personal protective equipment (PPE).

As a result, the hospital was found out of compliance with the Conditions of Participation Infection Prevention and Control and Antibiotic Stewardship Programs at 42 CFR 482.42.

A condition level deficiency was issued at A0747. See A0749 see for additonal information.

Based on observation, interview, and document review, the facility failed to ensure staff followed infection control measures for one of ten patients (P7) reviewed when staff provided direct patient care to a patient on contact precautions without using the required personal protective equipment (PPE).

Findings include:

During an observation of the cardiovascular intensive care unit (CVICU) on 3/31/25 at 9:53 a.m., an isolation cart stocked with gloves, reusable gowns, surgical masks, and eye protection was sitting directly outside P7's. The sign on the left of the doorway indicated "Contact Precautions. Everyone must clean hands before entering, and after exiting. Staff entering beyond the swing of the door must. Before entering: Put on gown. Put on gloves. Before exiting: Take off gown. Take off gloves." The curtain was drawn, and three sets of feet could be seen around a wheelchair. When the curtain opened, three direct care staff members, including registered nurse (RN)-A, were readjusting P7 in a wheelchair at the bedside. None of the staff members were wearing reusable contact precaution gowns but all were wearing gloves. While at the entrance of P7's room, RN-A spoke with another staff member, pulled her hospital phone out of her scrub pockets, and began a conversation over the phone. RN-A had not exited P7's room and her gloves were not doffed. The two other staff members removed their gloves and performed hand hygiene with foaming hand sanitizer prior to leaving the room. At 9:57 a.m., RN-A exited P7's room, with gloves on, and donned a reusable contact precaution gown, then reentered the room. RN-A hung up the phone and put it back into her pocket. At 9:59 a.m. another staff member donned a reusable gown and gloves, entered P7's room, and then escorted P7 off the unit. RN-A doffed her reusable gown and disposed of her gloves, performed hand hygiene with foaming hand sanitizer, and then entered another patient room.

P7 was a 60-year-old female who admitted directly to the medicine/surgery unit of the hospital on 3/25/25 at 10:02 a.m. for planned perioperative antibiotic treatment. P7's relevant medical diagnoses include chronic respiratory failure, ataxia, coordination impairment, history of cerebrovascular accident, unilateral hemiparesis, obesity, nephrolithiasis, and left-sided nephrostomy tube.

An order for contact isolation dated 3/25/25 indicated P7 was on continuous contact isolation. The contact order did not identify the medical indication.

On 3/26/25 at 4:53 p.m., P7 underwent a urologic procedure to remove an obstructive ureteral stone, placement of a ureteral stent, and removal of the left-sided nephrostomy tube. No complications were noted.

On 3/26/25 at 6:57 p.m., P7 was transferred to the post anesthesia care unit.

On 3/26/25 at 9:12 p.m., P7 was transferred to the medical/surgical unit.

A rapid response team note indicated on 3/26/25 at 11:05 p.m. a rapid response was initiated for a P7's critical lab values with concerns for septic shock. The rapid response concluded on 3/27/25 at 1:50 a.m.

On 3/27/25 at 1:34 a.m., P7 was transferred to the CVICU.

A provider note dated 3/29/25 at 10:14 a.m. indicated cultures collected during P7's surgery on 3/27/25 were positive for Escherichia coli extended spectrum beta lactamase (ESBL) and gram-negative bacilli. The note indicated ESBL producing organisms require contact precautions.

A nursing note dated 3/30/25 at 5:45 a.m. indicated P7 had two episodes of watery stool overnight.

Specimen collection and results data for C. difficile Toxin B PCR with reflex to C. difficile EIA, dated 3/30/25 at 12:57 p.m. indicated P7 was negative for C. difficile.

An order for enteric precautions dated 3/30/25 at 10:10 a.m. indicated P7 was on continuous enteric isolation.

A nursing note dated 3/30/25 at 2:46 p.m. indicated P7 continued to have loose stools, and a C. difficile culture was negative.

During an interview on 3/26/25 9:47 a.m., RN-B stated if a patient is on enteric or contact isolation, there should be a sign outside their door and a fully stocked precaution cart. RN-B stated staff must follow the signs outside the door and don appropriate PPE prior to entering. RN-B stated staff must wash their hands after caring for a patient on enteric precautions.

During an interview on 3/26/25 at 10:14 a.m., RN-C stated if a patient is on enteric precautions or specific signage directing staff, they should always wash their hands with soap and water after providing patient care.

During an interview on 3/26/25 at 11:32 a.m., RN-D stated if a patient is on enteric isolation or a staff members' hands are visibly soiled, staff must wash their hands prior to exiting the room.

During an interview on 3/31/25 at 10:09 a.m., RN-A stated if a patient is on contact isolation, staff must wear gloves, a gown, and potentially eye protection if there is concern for bodily fluids splashing. RN-A stated patients who are on contact isolation are indicated by the sign on the door. RN-A stated when accessing a patient's electronic medical record, any patient specific precautions will show on the left side of the navigator, and indications can be found by reading nursing or provider notes. RN-A stated it is the nurse's responsibility to know why their patient may be on any precautions. RN-A stated she "forgot to put on a gown," when she entered P7's room. RN-A stated she entered P7's room to speak with the patient, but while she was there, P7 requested to be transferred to her wheelchair. RN-A stated she then called for assistance from other nursing staff, and two additional direct care staff assisted with P7's transfer without wearing reusable gowns. RN-A stated she did not know why P7 was on contact isolation or enteric isolation.

During an interview on 3/31/25 at 10:28 a.m., RN-E stated it is the responsibility of the nurse to check if the precaution sign on the patient's door matches the precautions listed in their medical record. RN-E stated if a patient's room does not have appropriate signage, she would notify the direct care staff, place a pre-made sign on the door, and request a precaution cart be placed outside the patient's room immediately.

During an interview on 4/1/25 at 11:02 a.m., RN-F, nurse manager, stated the unit conducts contact and isolation precaution, and hand hygiene audits every month, thirty times per month monitoring their compliance rates. Every day environmental staff cleans patient rooms, nurse aid staff wipe down high touch areas in patient rooms such as keyboards and doorknobs, ect., and nurses disinfect patient equipment after use.

During an interview on 4/1/25 at 2:09 p.m., the system program manager stated when the unit conducts their infection control audits if a staff is found to not adhere to infection control standards staff are given "just in time" education informing the staff of the missed protocol. The staff conducting the audit include nursing, regulatory, or the infection preventionist.

In an email correspondence sent on 4/1/25 at 3:53 p.m., they system program manager stated RN-A completed annual mandatory education regarding hand hygiene and contact isolation on 2/9/25.

A training titled 2025 Mandatory Annual Education Lesson 3, transmission-based precautions are used when a patient is known or suspected of having a disease which may spread to others. The training indicated contact precautions are used when caring for patients with suspected or confirmed multidrug-resistant organisms. The training indicated contact precautions include staff wear a gown and gloves when entering the room. The training indicated enteric precautions are used when caring for patients with suspected clostridium difficile. training indicated contact precautions include staff weary a gown and gloves when entering the room, and cleanse their hands with soap and water, not alcohol-based hand rub, when exiting the room.

A policy titled Hand Hygiene - Hand Washing dated 10/9/24, indicated hand washing with soap and water is required when caring for patients in enteric precautions rooms.