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A. Based on document review, observation, and interview, it was determined that for 2 of 3 (Pts. #1 and #3) patients with infections, the Hospital failed to ensure that isolation precautions were implemented to prevent and control the transmission of infections.

Findings include:

1. The Hospital's policy titled, "Isolation" (revised 4/5/2023), was reviewed and required, "Inpatient departments will initiate isolation based on transmission based precautions recommendations from the Centers for Disease and Control (CDC) see Exhibit A... Contact Isolation: 1. Place patient in a private room with appropriate isolation sign posted outside room. 2. a. Gown and gloves when entering the patient's room or treatment area... Exhibit A Isolation Guidelines: ...Infection/Condition: Extended-spectrum beta-lactamase (ESBL) [and] Multi-drug resistant organism (MDRO) [and] (VRE); Precautions Required: Contact... [for] Infection- current or within the past year..."

2. The clinical record of Pt. #1 was reviewed on 3/4/2024. Pt. #1 was presented to the Hospital on 10/16/2023 with a chief complaint of diarrhea. A body fluid culture, collected on 11/2/2023 and resulted on 11/5/2023, was positive for VRE [vancomycin-resistant enterococcus]. A contact isolation order was placed on 11/5/2023. The clinical record included nursing education notes regarding isolation starting on 11/9/2023 (4 days after the order was placed). In addition, the nursing flowsheet lacked documentation indicating that precautions were implemented and in place.

3. The clinical record of Pt. #3 was reviewed on 3/5/2024. Pt. #3 was admitted on 3/2/2024 with a diagnosis of MDRO e. [escherichia] coli UTI [urinary tract infection]. The History and Physical, dated 3/2/2024 at 8:56 AM, included "[Pt. #3] presenting to the ED [emergency department] for UTI requiring admission for IV [intravenous] antibiotics... Differential diagnosis includes ESBL UTI... Previous records reviewed. Urine culture obtained February 24, 2024 was positive for ESBL..." The record lacked orders and implementation of contact precautions as required for ESBL infections.

4. During a tour of the Medical-Oncology Unit on 3/4/2024, at approximately 9:50 AM. Pt. #3's room was observed and lacked signage posted to indicate Pt. #3 was on contact precautions. Staff entering the room did not don gloves and gown.

5. An interview was conducted with the Manager of Infectious Disease (E#20) on 3/6/2024, at approximately 10:52 AM. E#20 stated if a patient has a current infection or infection within the past year with a MDRO, the patient will be placed on contact precautions. E#20 stated that Pt. #3 should have been on contact precautions. E#20 stated that if the cultures were done at the Hospital, it would normally flag the record to order the precautions. E#20 stated that in Pt. #3's case, the results were from the another hospital and should have been ordered by the nurse or physician when doing the admission screening and assessments.

6. An interview was conducted with the Nurse Educator (E#21) on 3/6/2024, at approximately 12:35 PM. E#21 stated that when an order is placed for isolation, the nurse should acknowledge the order and document that education was provided regarding the isolation precautions and MDROs.


B. Based on document review, observation, and interview, it was determined that for 3 of 4 staff (E#6-#8) observed providing patient care, the Hospital failed to ensure that hand hygiene was performed to prevent and control the transmission of infections.

Findings include:

1. The Hospital's policy titled, "Standard Precautions" (revised 11/3/2021), was reviewed and required, "Perform hand hygiene in the following situations: ... before donning gloves and after removing gloves..."

2. During a tour of Medical Oncology Unit on 3/4/2024 the following was observed:
- At approximately 9:40 AM. Registered Nurse/RN (E#6) was observed administering IV [intravenous] antibiotics to Pt. #2. E#6 moved the garbage bin closer to the bedside and then changed gloves without performing hand hygiene. E#6 proceeded to connect the IV lines to the pump.
- At approximately 9:50 AM, RN (E#7) was observed administering antibiotics to Pt. #3 through the patients newly placed PICC [peripherally inserted central catheter]. E#7 connected the IV tubing to Pt. #3's PICC port and then changed gloves without performing hand hygiene.
- At approximately 10:21 AM, RN (E#8) was observed administering a medication IV push to Pt. #5. E#8 wiped the IV port with alcohol and went to throw away the pad in the garbage. E#8 used the left gloved hand to lift the garbage lid. E#8 then went back to administer the medication through the patient's peripheral IV line without changing gloves and performing hand hygiene. After administering the medication, E#8 changed gloves without performing hand hygiene.

3. An interview was conducted with Registered Nurse (E#6) on 3/4/2024, at approximately 11:10 AM. E#6 stated that hand hygiene should be done before putting on gloves and after removing them.