HospitalInspections.org

Based on review of facility policies, observations and interviews, it was determined the facility staff failed to follow their infection control policy for contact isolation. This had the potential to negatively affect all patients admitted to this facility.

Findings include:

Policy: IC III-3
Determination of Isolation

Policy:

... C. All departments within the Hospital will follow precaution techniques outlined in this manual. These procedures will be followed when personnel enter the room for a patient in isolation, as well as when the patient must be seen in other areas of the host hospital or outside facilities.

D. Isolation Signs:

... 2. Precaution signs will include: Airborne, Contact, Contact Enteric, and Protective Environment Precautions.

Policy: IC III-5

Contact/Contact Enteric Precautions

The policy of the Hospital is to prevent transmission of highly transmittable or epidemiologically important infections by direct or indirect contact. Because of the fragility of the patient population and the high degree of MDRO (Multi-drug resistant organisms) colonization and infections at the time of admission, these have been expanded beyond the 2007 CDC (Centers for Disease Control) Guideline.

Principles

... A. Sufficient precautions to control cross-infection in this category of isolation include proper hand hygiene, handling of linen, dressings and contaminated instruments, and the use of gowns, masks and gloves when stipulated.

B. This category includes excessive wound drainage, fecal incontinence, or other types of drainage or patients colonized with MRDOs...

... Procedures

... B. Specific Procedures:

2. A sign reading "Contact Precautions" will be posted on the door and on the patient's chart. If the patient is in contact precautions for enteric illness such as C-diff (Clostridium difficile)/ Novovirus, then use the Contact Special Enteric Precautions sign to prompt the staff to perform hand hygiene with soap and water. PPE (personal protective equipment) will be available at the entrance to the room.

3. Gowns should be worn when soiling will be likely to occur or when contact with the patient or environmental surfaces that have been contaminated will occur...


During a tour of the facility on 12/2/14 at 9:10 AM, the surveyor observed located on the door of patient room number 923 a sign indicating the patient was on "Contact Isolation". The surveyor observed Employee Identifier (EI) # 2, Registered Nurse (RN) in the patient's room administering medication via PEG (Percutaneous endoscopic gastrostomy) tube. EI # 2 was wearing gloves, but did not have on a gown.




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2. During an observation on 12/3/14 at 8:30 AM, the surveyor observed located on the door of patient room number 938 a sign indicating the patient was on "Contact Isolation". The surveyor observed Employee Identifier (EI) # 3, Nursing Assistant in the patient's room at the bedside and was not wearing a gown. EI # 3 was wearing gloves, but did not have on a gown.