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Based on review of hospital policies and procedures, job descriptions, medical record review and staff interview, the nursing staff failed to supervise and evaluate patient care by failing to place a patient with a known history of an infectious disease on isolation for 2 of 3 patients with infectious disease reviewed (#7, #11).

The findings include:

Review of the hospital policy, "Multi-Drug Resistant Organism Management: Methicillin Resistant Staph Aureus (MRSA...)", revised 06/2009, revealed, "Policy It is the policy of (hospital name) that all patients that have been on contact isolation on previous admissions and/or have had a positive culture for MRSA...will have their charts (face sheet) flagged. ... Purpose Patients who have been on contact isolation on previous admissions and/or have had a positive culture for MRSA...will have a shaded I appear on their face sheet. This will appear on the face sheet each time the patient is registered in the hospital system. The purpose is to alert the staff that the patient needs to be on contact isolation. Procedure All patients who have had a positive culture for MRSA...will have their charts flagged. ...If the patient is admitted, these patients will remain on contact isolation throughout their stay. Guidelines for discontinuing Contact Precautions: Once MRSA...has been isolated from a patient, contact precautions shall remain in effect until screened by the Infection Control Practitioner and current CDC (Centers for Disease Control) recommendations are followed.

Review of the job description for "Admissions RN (Registered Nurse)", not dated, revealed "Job Summary Administers nursing care to patients according to principles of nursing practice, physician's orders, and Hospital policy. Performs admissions process and ...communicates care interactions to receiving unit's nurse. ...".

Review of the job description for "RN, Med-Surg", not dated, revealed "Job Summary Administers nursing care to patients according to principles of nursing practice, physician's orders, and Hospital policy. ...".

1. Open record review on 02/22/2011 of Patient #7 revealed a 78 year-old admitted 02/18/2011 after falling at home and fracturing his left hip. Record review revealed a history of end-stage renal failure and hypertension. Record review revealed the patient had surgery on his left hip on 02/19/2011. Record review revealed a large-shaded I on the patient's face sheet. Further record review revealed an Admission Assessment was completed by the admission's nurse on 02/18/2011 at 2145. Review of the Admission Assessment revealed "Does the patient require any of the following Precautions? ...Contact Precautions: N (No)...". Further record review revealed a shift assessment completed by the registered nurse at the following times: 02/19/2011 at 0805, 02/19/2011 at 2010, 02/20/2011 at 0755, 02/20/2011 at 2000, 02/21/2011 at 0800, 02/21/2011 at 2145, 02/22/2011 at 0100, 02/22/2011 at 0500, 02/22/2011 at 0745 and 02/22/2011 at 0805. Review of the shift assessments revealed, "Does the patient require any of the following Precautions? ...Contact Precautions: N (No)...". Record review revealed Patient #7 was placed on contact precautions 02/22/2011 at 1000. Further record review revealed no documentation that Patient #7 was placed on contact precautions on 02/18/2011, 02/19/2011, 02/20/2011 and 02/21/2011.

Interview on 02/23/2011 at 0925 with Registered Nurse #1 revealed the nurse is a staff nurse on the medical-surgical unit. Interview revealed, "the I on the face sheet means a history of something, probably MRSA. (Name of patient) should have been placed on contact isolation. We should be checking it every shift to make sure it's done." Interview further revealed, "our policy was not followed".

Interview on 02/23/2011 at 1040 with Registered Nurse #2 revealed the nurse was Patient #7's primary nurse on 02/19/2011 beginning at 0700. Interview revealed, "the I on the face sheet means the patient should be placed on contact isolation. I did not check the face sheet at the start of my shift and I didn't place him on contact precautions". Interview further revealed, "I did not follow our policy".

Interview on 02/22/2011at 1330 with Registered Nurse #3 revealed the nurse placed Patient #7 on contact precautions 02/22/2011 at approximately 1030. Interview revealed "the large I on his face sheet indicates he has a history of MRSA. I placed him on contact precautions pending the results of sputum and blood cultures". Interview further revealed Patient #7 should have been placed on contact isolation when admitted on 02/18/2011.

2. Open record review on 02/23/2011 of Patient #11 revealed a 27 year-old admitted 02/21/2011 with abdominal pain and diarrhea. Record review revealed a large-shaded I on the patient's face sheet. Further record review revealed an Admission Assessment was completed by the admission's nurse on 02/21/2011 at 2031. Review of the Admission Assessment revealed "Does the patient require any of the following Precautions? ...Contact Precautions: N (No)...". Further record review revealed a shift assessment completed by the registered nurse on 02/22/2011 at 0800 and 2030. Review of the shift assessments revealed, "Does the patient require any of the following Precautions? ...Contact Precautions: N (No)...". Further record review revealed no documentation that Patient #7 was placed on contact precautions on 02/21/2011 and 02/22/2011.

Interview on 02/23/2011 at 0930 with Registered Nurse #4 revealed the nurse was the charge nurse on the unit. Interview revealed, "I placed the patient on contact precautions this morning when I noticed the 'I' on her face sheet. This means the patient has a history of MRSA. I don't know why she wasn't placed on isolation before now". Further interview revealed, "we didn't follow our policy".

Interview on 02/23/2011 at 1355 with Registered Nurse #5 revealed the nurse was the admission nurse on 02/21/2011 when Patient #11 was admitted. Interview revealed, "I should have reviewed the face sheet and placed the patient on contact isolation. If I didn't have the face sheet, I should have checked in the computer". Interview further revealed, "I made a mistake by not following policy".

Based on review of hospital policies and procedures, medical record review, infection control log review and staff interviews, the hospital failed to ensure their infection control policies were followed for 2 of 3 patients requiring isolation (#7, #11).

The findings include:

Review of the hospital policy, "Multi-Drug Resistant Organism Management: Methicillin Resistant Staph Aureus (MRSA...)", revised 06/2009, revealed, "Policy It is the policy of (hospital name) that all patients that have been on contact isolation on previous admissions and/or have had a positive culture for MRSA...will have their charts (face sheet) flagged. The Infection Control Practitioner will enter these patients into Medi-Tech (electronic medical record). Only the Infection Control Practitioner will have access to make changes to this screen. Purpose Patients who have been on contact isolation on previous admissions and/or have had a positive culture for MRSA...will have a shaded I appear on their face sheet. This will appear on the face sheet each time the patient is registered in the hospital system. The purpose is to alert the staff that the patient needs to be on contact isolation. Procedure All patients who have had a positive culture for MRSA...will have their charts flagged. ...If the patient is admitted, these patients will remain on contact isolation throughout their stay. Guidelines for discontinuing Contact Precautions: Once MRSA...has been isolated from a patient, contact precautions shall remain in effect until screened by the Infection Control Practitioner and current CDC (Centers for Disease Control) recommendations are followed.

1. Open record review on 02/22/2011 of Patient #7 revealed a 78 year-old admitted 02/18/2011 after falling at home and fracturing his left hip. Record review revealed a history of end-stage renal failure and hypertension. Record review revealed the patient had surgery on his left hip on 02/19/2011. Record review revealed a large-shaded I on the patient's face sheet. Further record review revealed an Admission Assessment was completed by the admission's nurse on 02/18/2011 at 2145. Review of the Admission Assessment revealed "Does the patient require any of the following Precautions? ...Contact Precautions: N (No)...". Further record review revealed a shift assessment completed by the registered nurse at the following times: 02/19/2011 at 0805, 02/19/2011 at 2010, 02/20/2011 at 0755, 02/20/2011 at 2000, 02/21/2011 at 0800, 02/21/2011 at 2145, 02/22/2011 at 0100, 02/22/2011 at 0500, 02/22/2011 at 0745 and 02/22/2011 at 0805. Review of the shift assessments revealed, "Does the patient require any of the following Precautions? ...Contact Precautions: N (No)...". Record review revealed Patient #7 was placed on contact precautions 02/22/2011 at 1000. Further record review revealed no documentation that Patient #7 was placed on contact precautions on 02/18/2011, 02/19/2011, 02/20/2011 and 02/21/2011.

Review of the Infection Control Log on 02/22/2011 and 02/23/2011 revealed no documentation that Patient #7 was on contact isolation due to a history of MRSA.

Interview on 02/23/2011 at 1235 with the Infection Control Practitioner revealed Patient #7 should have been placed on contact precautions on admission 02/18/2011 due to a history of MRSA. Interview further revealed, "I do not get a list of patients who are admitted with a history of infectious disease. I spot check when I make rounds to see if patients who need to be on isolation are on isolation. I do not have time to check every single face sheet for the 'I'". Interview further revealed "our nurses need more education and we need a better system to make sure this is done". Interview confirmed that Patient #7 had a history of MRSA and should have been placed on contact isolation 02/18/2011, 02/19/2011, 02/20/2011 and 02/21/2011. Interview confirmed the hospital's infection control policy was not followed.

2. Open record review on 02/23/2011 of Patient #11 revealed a 27 year-old admitted 02/21/2011 with abdominal pain and diarrhea. Record review revealed a large-shaded I on the patient's face sheet. Further record review revealed an Admission Assessment was completed by the admission's nurse on 02/21/2011 at 2031. Review of the Admission Assessment revealed "Does the patient require any of the following Precautions? ...Contact Precautions: N (No)...". Further record review revealed a shift assessment completed by the registered nurse on 02/22/2011 at 0800 and 2030. Review of the shift assessments revealed, "Does the patient require any of the following Precautions? ...Contact Precautions: N (No)...". Further record review revealed no documentation that Patient #7 was placed on contact precautions on 02/21/2011 and 02/22/2011.

Review of the Infection Control Log on 02/22/2011 and 02/23/2011 revealed no documentation that Patient #11 was on contact isolation due to a history of MRSA.

Interview on 02/23/2011 at 1235 with the Infection Control Practitioner revealed Patient #7 should have been placed on contact precautions on admission 02/18/2011 due to a history of MRSA. Interview further revealed, "I do not get a list of patients who are admitted with a history of infectious disease. I spot check when I make rounds to see if patients who need to be on isolation are on isolation. I do not have time to check every single face sheet for the 'I'". Interview further revealed "our nurses need more education and we need a better system to make sure this is done". Interview confirmed that Patient #11 had a history of MRSA and should have been placed on contact isolation 02/21/2011 and 02/22/2011. Interview confirmed the hospital's infection control policy was not followed.

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