HospitalInspections.org

Based on a tour of the facility, review of facility documentation and medical records (MR), and staff interview(EMP), it was determined the facility failed to follow policy and procedures for three of three medical records reviewed (MR2, MR3, and MR4).

Findings include:

Review of facility policy and procedure "Isolation Standard Precautions Policy" dated January 27, 2014, revealed "5. Education of HCW'S (health care workers), patients and families. Healthcare workers will receive training on Standard and Transmission based Precautions during orientation and annually thereafter. It is the responsibility of Healthcare providers to educate patients and visitors about the use of precautions and their responsibility for adherence to them ... Document all education in the patient record."

1. During a tour of the fourth floor it was discovered that rooms 5, 7, and 9 were occupied with patient in isolation precautions.

2. Review of MR2 and MR3 revealed no physician order to place the patients in isolation. Further review revealed no documentation of when the patients were placed in isolation or that education was provided, as per facility policy.

Interview with EMP2 on June 3, 2014, at approximately 9:40 AM confirmed the above findings and revealed "We follow ABA (American Burn Association) guidelines. All burns are placed in isolation. It [medical record] probably won't say they are in isolation. No, it's [physician order and documentation of isolation] not there."

3. Review of MR4 revealed no physician order to place the patient in isolation. Further review revealed no documentation of when the patient was placed in isolation or that education was provided, as per facility policy.

Interview with EMP2 on June 3, 2014, at approximately 9:55 AM confirmed the above findings and revealed, "That patient is in isolation to rule out [awaiting results of cultures], but it doesn't reflect it in the medical record."