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Based on observations and staff interviews conducted during the survey, it was determined the facility failed to ensure the Infection Control Policy and Procedures are consistently implemented for 3 sampled patients (#2, #3, #5) and, 6 randomly observed patients (#7, #9, #11, #14, #15 and #16).

The findings include:

Review of the facility policy and procedure titled Contact Precautions is a method to reduce the risk of transmission of micro- organisms by direct and indirect contact. Contact Precautions are used for patients with known or suspected infections or evidence of syndromes that represent an increased risk of contact transmission.

Precautions also apply where the presence of excessive wound drainage, or other discharges from the body suggest an increased potential for extensive environmental contamination and the risk for transmission.

The Hand Hygeine and the Contact Precautions Policy and Procedure require hands to be washed after gloves are removed.

1) Patient #2 was readmitted to the facility 1/12/11. The patient is on Contact Isolation for
Methicillin Resistant Staphlococcus Aureus (MRSA). There was a Contact Isolation sign on
the door. A family member was observed in the room at 12:30 PM on 01/31/11.
The family member was not wearing personal protective equipment (PPE). Upon inquiry the
family member stated the patient was admitted 12/28/10 and at that time she wore the gown
and gloves; the patient was transferred to the hospital on 1/9/11 for a Small bowel
Obstruction returning on 1/12/11. The family member stated they told me I did not have to
wear the gown.

2) Patient #3 was admitted to the facility 10/18/10. The patient is on Contact Isolation for Methicillin Resistant Staphlococcus Aureus (MRSA) and Pseudomonas. The positive cultures were reported on 01/14/11. The patient was receiving Hemodialysis treatment at 1330 hours on 1/31/11. There was no Contact Isolation sign on the door.

A family member was observed in the room at 1330 hours. The family member was not wearing personal protective equipment (PPE). A nurse was observed entering the room to deliver 2 units of blood to the dialysis nurse. The nurse did not wear PPE. The nurse later returned to the room to check the unit of blood with the dialysis nurse. The nurse did not don the PPE.

3) Patient #5 was admitted to the facility 01/19/11. The patient ' s heart valve is infected with Staphlococcus Aureus. The patient is on Contact Isolation for Methicillin Resistant Staphlococcus Aureus (MRSA) in sputum. There was a Contact Isolation sign on the door. A family member was observed in the room at 1410. The family member was not wearing (PPE). The family member was not aware the PPE was required. The family member was asked if staff wear PPE when providing care. The family member stated, " It depends on the nurse. Some do and some do not."

4) Patient #11 is on Contact Isolation for Methicillin Resistant Staphlococcus Aureus (MRSA) in his sputum.

A medication pass was observed on 02/1/11 at 1310. A family member was observed in the room at 1310. The family member was not wearing personal protective equipment (PPE). The nurse was unaware that the family member was not wearing PPE.
The nurse donned a gown and gloves and entered the room to speak with the family member.
The family member stated she was not going to wear the PPE. The supervisor was informed of the family member refusal to wear PPE. The nursing supervisor educated the family member as to isolation precautions. The family member then complied with the isolation precautions.

5) Patient #14 is on Contact Isolation. On 01/31/11 at 1600 a Respiratory Therapist (RT) was observed in the room. The RT was not wearing personal protective equipment (PPE).

6) On 01/31/11 at 1150 a nurse was observed providing care to patient # 9.
The nurse removed his gloves but failed to wash his hands before leaving the room.
A wound - Vac was observed on the floor. The nurse stated the Wound-Vac had just been removed from the patient's wound.

7) On 01/31/11 at approximately 1200 the housekeeping cart was observed outside of room 221. A bottle of Starbucks Coffee was stored on top of the cart.

The above observations were made during the tour of the facility accompanied by the Clinical Nurse Manager.