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CLEVELAND CLINIC 9500 EUCLID AVENUE CLEVELAND, OH 44195 June 4, 2019
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on review of facility policies, medical record review, and staff interview, the facility failed to ensure isolation protocols were followed and patients/visitors were educated on isolation precautions when in place for one of 12 medical records reviewed (Patient #10). This had the potential to affect all patients receiving services from this facility. The patient census was 1065.

Findings include:

Review of the "Contact Precautions Policy" effective 12/12/18 revealed contact precautions would be applied to any patient with confirmed or suspected infection that can be transferred from person to person with direct or indirect contact. An isolation order would be obtained and a contact precautions sign would be posted on the patient's door or bed space. Hand hygiene, gowns, and gloves were to be worn on entering the patient's room and disposed of on exiting the room. Patient and family may be provided educational materials. Visitors are not required to wear gowns or gloves unless providing direct care to the patient. Visitors should be instructed to perform hand hygiene when entering or leaving the room.

Review of the "Patient and Family Education Standard Operating Procedure" effective 07/27/16 revealed educational needs should be assessed and revised during the hospital stay, documented in the Patient Education Module, and educational materials should be provided during instruction.

Review of the medical record for Patient #10 revealed a urine culture draw on 04/20/19 was positive for Klebsiella CRE positive (Carbapenemase resistant enterobacteriaceae). The lab report noted nursing was notified on 04/23/19 at 2:00 PM of the positive CRE culture and need for contact isolation. An order dated 04/24/19 at 2:46 AM ordered contact precautions. Review of the nursing flowsheets noted the first documentation of contact precautions was on 04/24/19 at 8:00 AM. The flowsheets after this date contained documentation of contact precautions through out the remainder of the hospital stay. Staff F documented in a progress note dated 04/24/19 at 8:17 AM that contact precautions were initiated and would remain in place for the remainder of the hospitalization . Review of patient and family education noted the only education related to infection control and isolation precautions was completed between 03/01/19 and 03/19/19. The medical record lacked documentation of an order for contact precautions between 04/23/19 at 2:00 PM and 04/24/19 at 2:46 AM and lacked documentation that contact precautions were initiated or in place between 04/23/19 at 2:00 PM and 04/24/19 at 8:00 AM. The medical record lacked documentation the patient or family were educated on the need for contact precautions or what that would mean for visitors. This was verified in an interview on 06/03/19 at 3:00 PM by Staff D.

During interview on 06/04/19 at 11:35 AM, Staff F and G stated when notified of a positive culture requiring isolation, they would check the medical record for documentation of orders and taht the correct isolation precautions were in place. When they have found a record without the required order, they would call the nursing unit and almost always have found the patient had already been placed in isolation. They would then write the order and would enter a progress note with the type and reason for isolation. The staff should be documenting education, should be care planning the precautions, and should be documenting the precautions were in place. CRE patients were always placed in isolation and would be placed directly into contact precautions at admission for any future hospital stays.

This substantiates Substantial Allegation OH 004.