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Based on record reviews and interviews, the hospital failed to track quality indicators for the isolation precaution protocol for patients with suspected infections identified on 5/12/10 as evidenced by failing to have the "Tracer Audit" tool completed in order to track and analyze the nursing staffs compliance with following the "Isolation Precaution" policy and failing to implement an action plan after the nurses had continued non-compliance to follow the "Isolation Precaution" policy for patients with suspected infections from 5/12/10 through 9/28/10. Findings:

Review of the "Infection Control Survey, Nursing Services, ICU/CCU" forms completed by the Infection Control Coordinator, (S4) from 5/12/10 through 8/4/10 revealed there was no documented evidence of the quality indicators used to track and analyze the nurses non-compliance with initiating and implementing the "Isolation Precaution" policy from 5/12/10 through 9/28/10. Further review revealed there was no documented evidence that an action plan was implemented when the "Tracer Audit" tool was not being completed by the nursing departments to track the nurses non-compliance with the "Isolation Precaution" policy from 5/12/10 to 9/28/10.

Review of the Performance Improvement Meeting Minutes held on 7/30/10 revealed Quality Director (S3), Performance Improvement (S5) and Infection Control Coordinator (S4) there was an ongoing problem with patients isolation precaution protocols being followed by the nursing staff identified since 5/12/10 through 7/30/10. Further review revealed there was no documented evidence that the quality indicator tracking for the nurses compliance with following the "Isolation Precaution" policy was presented from July through 9/28/10. Further review revealed there was no documented evidence presented of an action plan implemented after the ongoing problem with nurses to follow the "Isolation Precaution" policy from 5/12/10 to 9/28/10.

In face-to-face interview conducted on 9/28/10 at 2:00 pm, Infection Control Coordinator (S4) indicated the hospital's Quality Program identified there were an ongoing problem with the nursing staff to initiate and follow the "Isolation Precaution" policy for patients with suspected infections that was identified on 5/12/10. She reported the "Tracer Audit" tool was implemented after the nurses non-compliance was identified to track the nurses compliance with the policy. She indicated there was a current ongoing non-compliance as of today, 9/28/10 with tracking the quality indicators to determine the nurses compliance with following the "Isolation Precaution" policy. She reported there was no action plan implemented after the Medical Staff and DON (S2) were notified on 5/12/10 and 7/30/10 (at the Performance Improvement Meeting) of the non-compliance with both the department heads completing the "Tracer Audit" tool used to track the nurses continued non-compliance with following the "Isolation Precaution" policy.

The policy titled, " Isolation, Initiating " , Number: IC.5, Effective date of 9/92, Review date of 2/1008, Reference CDC Guidelines for Isolation Precautions June, 2007, pages 1 to 2, read in part, " The Infection Control Team shall be triggered for patients admitted with a communicable disease or contagious disease or suspicion of a communicable disease. When lab work reports suggest a contagious disease, trigger Infection Control".

Review of the hospital Bylaws, with a revised date of 9/2007, Article IX INFECTION CONTROL, revealed in part, "Any patient with a known or suspected communicable disease or infection shall consult the Infection Control Team. When a series of infections, including post-operative infections occur and infections of epidemic proportion, the Infection Control Coordinator in consult with the Infection Control Team shall initiate procedures necessary to investigate and prevent further spread of infection. All Medical Staff members shall be required to comply with appropriate infectious disease policies and procedures of the hospital".

Based on record reviews and interview, the Quality Assurance Program failed to have data collected to monitor the quality of care for patients with suspected infections as evidenced by failing to have complete data collected to track the nurses' non-compliance with following the "Isolation Precaution" policy for patients with suspected infections since 5/12/10 and failing to monitor and evaluate the quality of care that these patients had from 5/12/10 until current, 9/28/10. Findings:

Review of the "Infection Control Survey, Nursing Services, ICU/CCU" forms completed by the Infection Control Coordinator, (S4) from 5/12/10 through 8/4/10 revealed there was non-compliance with the "Tracer Audit" tool used to track and trend the nurses compliance with following the "Isolation Precaution" policy from May through August of 2010. Further review revealed there was no documented evidence of the data collected to monitor and evaluate the quality of care for patients with suspected infections from 5/12/10 until 8/4/10. There was no documented evidence presented of the data collected to track, monitor or evaluate the quality of care that the patients with suspected infections from 5/12/10 through 9/28/10. Further review revealed there was no documented evidence that the program monitored the effectiveness of services and/or quality of care for the nurses continued non-compliance with following the "Isolation Precaution" policy from 5/12/10 through 9/28/10.

Review of the Performance Improvement Meeting Minutes held on 7/30/10 revealed there was non-compliance with the data collected, ("Tracer Audit" forms) being completed from May through July of 2010. Further review revealed there was no documented evidence that the program monitored and/or evaluated the quality of care for patients with suspected infections from May to July of 2010. There was no documented evidence that the data collected to track, trend, monitor and evaluate the nurses continued non-compliance with following the "Isolation Precaution" policy presented from 5/12/10 through 9/28/10.

In face-to-face interview conducted on 9/28/10 at 2:00 pm, Infection Control Coordinator (S4) indicated the hospital's Quality Program identified there was current non-compliance with the data, ("Tracer Audit" forms) being completed to track and monitor the patient's with suspected infections. She reported there was no documented evidence that the patients with suspected infections was monitored and evaluated for the quality of care provided to them by the nurses from 5/12/10 through present, 9/28/10. She indicated there was incomplete data collected in order to evaluate the effectiveness of services provided to the patients from May to September of 2010.

Based on record reviews and interview, the Quality Assurance Program failed to have data collected to identify opportunities for improvement after the nursing staff failed to follow the isolation precautions protocol as a nursing intervention before/while obtaining an order as per policy that was identified since 5/12/10 to present, 9/28/10. Findings:

Review of the "Infection Control Survey, Nursing Services, ICU/CCU" forms completed by the Infection Control Coordinator, (S4) from 5/12/10 through 8/4/10 revealed there was non-compliance with the data collected, "Tracer Audit" tool to track the nurses compliance with following the "Isolation Precaution" policy from May through August of 2010. Further review revealed there was no documented evidence of the data collected used to identify and implement opportunities for improvement for the nurses continued non-compliance with following the "Isolation Precaution" policy from 5/12/10 until 8/4/10. There was no documented evidence presented of the data collected to identify and correct opportunities for improvement with the nurses continued non-compliance with following the "Isolation Precaution" policy from 8/4/10 to 9/28/10. Further review revealed there was no documented evidence that the program developed and implemented a plan to deal with the failure of the nursing staff to follow the "Isolation Precaution" policy from 5/12/10 through 9/28/10.

Review of the Performance Improvement Meeting Minutes held on 7/30/10 revealed there was non-compliance with the data collected ("Tracer Audit" forms) being completed from May through July of 2010. Further review revealed there was no documentation that the program developed and implemented a plan to deal with the nurses continued non-compliance to follow the "Isolation Precaution" policy from 5/12/10 through 7/30/10. There was no documented evidence the program developed and implemented a plan to deal with the nurses continued non-compliance to follow the "Isolation Precaution" policy presented from 5/12/10 through 9/28/10.

In face-to-face interview conducted on 9/28/10 at 2:00 pm, Infection Control Coordinator (S4) indicated the hospital's Quality Program identified there was current non-compliance with the data, ("Tracer Audit" forms) being completed to track the nurses ' compliance with following the "Isolation Precaution" policy that was identified since 5/12/10. She reported the program identified the nurses ' non-compliance with following the "Isolation Precaution" policy since 5/12/10. She indicated there was no change implemented after the program identified the nurses ' current non-compliance since 5/12/10 to present, 9/28/10. She further indicated that the program failed to develop and implement a plan to deal with the nurses continued non-compliance with following the "Isolation Precaution" policy from 5/12/10 to 9/28/10.

Based on record reviews and interviews the hospital failed to ensure the Registered Nurse followed hospital policy and procedure and Physician's Orders by failing to implement proper isolation precautions after positive culture results for MRSA (methicillin resistant staphylococcus aureus) were reported for 3 of 8 patients with MRSA positive cultures in a total sample of 20. (#14, #16, #19). Findings:

Patient #14

Review of the medical record of patient #14 revealed an admission date of 05/28/10 and blood cultures X 2 (2 sets) were ordered. Review of the laboratory final culture report released 05/31/10 at 0621 (6:21 a.m.) revealed the blood cultures were positive for MRSA.

Review of the nursing notes for 05/31/10 and 06/01/10 revealed documentation that patient #14 was on Standard Precautions. The patient was transferred to another hospital for higher level of care on 06/01/10.

In an interview on 09/24/10 at 11:00 a.m. with S3RN Director of Quality, S4RN Infection Control, and S5 PI Coordinator all stated that there was no documentation that patient #14's attending physician was notified of the MRSA, that the patient was placed on contact precautions on 05/31/10 when the positive culture was reported or that there was documentation of on going isolation per the hospital's policy number IC.5.

Patient #16

Review of the medical record of patient #16 was admitted on 05/06/10 with a tension pneumothorax. On 05/08/10 patient #16 was transferred to ICU (intensive care unit) after complications with the chest tube that required replacement. As part of the transfer to ICU a Nasal swab for MRSA was obtained on 05/08/10 at 12:33 p.m. Review of the laboratory final culture report dated/timed 05/10/10 at 9:01 a.m. revealed the culture was positive for MRSA.

Review of the nursing documentation for 05/10/10 and 05/11/10 revealed documentation that the patient was on standard precautions. Review of the nursing documentation for the 7 AM shift for 05/12/10 revealed the patient was now on contact precautions.

In an interview on 09/24/10 at 08:30 a.m. with S3RN Director of Quality, S4RN Infection Control, and S5 PI Coordinator all stated that there was no documentation that patient #16's attending physician was notified of the MRSA, that the patient was placed on contact precautions on 05/10/10 when the positive culture was reported or that there was documentation of on going isolation per the hospital's policy number IC.5 until 05/12/10 on the AM shift, 46 hours after the culture was reported positive for MRSA.

Patient #19

The medical record for Patient #19 was reviewed. Further review of the record revealed the attending physician wrote an order to admit the patient into the hospital to have an outpatient surgical procedure, (post operative repair of the left rotator cuff, incision, and drainage of the left shoulder) on 9/10/10. Further review of these physicians orders revealed there was no documentation of the time that the attending physician wrote the admission orders for the patient. Further review of the admitting physicians orders read, "Submit culture specimen to lab for C & S (culture and sensitivity) gram stain aerobic cultures". Further review of the attending physician orders revealed there were "Strict contact precautions" written for the patient on 9/12/10 at 7:30 pm (1930).

Review of the left, shoulder/drainage "microbiology routine culture results" collected on 09/09/2010 at 3:00 pm (1500) and released on 09/12/2010 at 7:21 am (0721) read, "Methicillin Resistant Staphylococcus aureus, (MRSA)".

Review of the "24 Hour Nursing Documentation NN24HR1" notes recorded by the nursing staff for Patient #19 on 9/12/10 read as follows: "Standard Infection Control Precautions in use" from 7:00 am to 7:00 pm shift and 7:00 pm to 7:00 am shift. Review of the "Interdisciplinary Progress Notes" recorded by the nurse for Patient #19 on 9/12/10 at 4:40 pm (1640) read as follows, "WD (wound culture) positive for MRSA...Isolation contact set up".

Further review of the "24 Hour Nursing Documentation NN24HR1" notes on 9/13/10 and 9/14/10 for Patient #19 revealed in part, "Standard Infection Control Precautions in use" was being implemented by the nursing staff during the day shift (7:00 am to 7:00 pm) and night shift (7:00 pm to 7:00 am).

Further review of the "Interdisciplinary Progress Notes" for Patient #19 on 9/13/10 at 8:30 pm (2030) revealed, "contact precautions in place" was recorded by the night shift nurse. Further review of the "Interdisciplinary Progress Notes" from 9/14/10 at 6:00 am (0600) through 9/15/10 at 8:00 pm (2000) revealed no documentation of the contact precautions implemented by the day and/or night shift nurses.

There was no documentation in Patient #19's medical record of the strict contact isolation precaution orders were implemented by the nursing staff for 12 hours during the night shift on 9/12/10 from 7:00 pm (1900) through 9/13/10 at 8:30 pm (2030)-12 hours. Further review of the record revealed there was no documented evidence the strict isolation precaution orders were implemented by the nursing staff for 23 hours from 9/14/10 at 6:00 am through 9/15/10 at 7:00 am.

During a face-to-face interview on 09/28/10 at 3:00 pm, the DON (S2) indicated she was responsible for the all of the nursing staff in the hospital. She reported there was current non-compliance of initiating and implementing the contact isolation precautions by the nursing staff per the "Isolation" policy or as ordered by the attending physicians after the patient's had tested positive for MRSA.

Review of the Opelousas General Hospital policy and procedure, policy number IC.5, Subject: Isolation, Initiating, effective date: 09/92, review date 02/2008, presented as current hospital policy reads in part: "Scope: Isolation applies to any patient registering at Opelousas General Hospital with a communicable disease. Responsibility/Authority: 1. All Opelousas General Hospital employees are responsible for initiating and maintaining isolation with the assistance of Infection Control and the authority of the attending physician. 2. Infection Control is responsible to assist with the initiating and maintaining of isolation. Policy:....2. All patients who have a diagnosis of a communicable disease or there is suspicion of the presence of communicable disease, shall be placed in isolation for prevention of spread of the disease.....Procedure: 1. When a patient is admitted with a communicable disease or contagious disease, or suspicion of a communicable disease, and the physician has not ordered isolation precautions, the nurse assigned to the patient must institute precautions immediately if found to be appropriate when utilizing the established guidelines.....The nurse must notify the attending physician as soon as possible, and write "isolation per hospital protocol" on the physician's order sheet. The nurse must also document when isolation is being enforced on a daily basis....3. When lab work or x-ray reports suggest a contagious disease, call the physician and request an order for isolation and trigger Infection Control..."

Review of the Opelousas General Health System Medical Staff Rules and Regulations, revised 02/2009, presented as current policy, reads in part: "Article IX Infection Control...2. Any patient with a known or suspected communicable disease or infection shall be isolated as required by the Infection Control Manual. The attending physician will be notified. The Infection Control Coordinator in consult with the Infection Control Team shall be empowered to order appropriate isolation procedures or epidemiologic investigations as required...."

Based on observations and interviews, the infection control officer or officers failed to develop a system for identifying, reporting, investigation, and controlling infections and communicable diseases of patients as evidenced by failing to maintain a sanitary hospital environment by having dirty patient equipment (computer keyboards, omnicell machines, computer documentation stations, stools, intravenous poles, mattress, bathroom floor tile, plastic pillow case) available for patient usage in Operating Room #2, Pre-Operative area, Recovery Room area, Cysto Room "a", and Same Day Surgery. Findings:

A tour of the Surgery Department was conducted from 2:00 pm through 4:00 pm on 9/27/10 with the Surgery Director (S12) and Infection Control Coordinator (S4). During this same observation, Operating Room #2 (OR#2) had a computer key board that was covered with plastic. This plastic had a whitish/gray substance inside the grooved areas of the key board. Further observation revealed, the Pre-Operative Area had five (5) omnicell machines with a plastic covering over the computer's key board. This clear plastic coating on the key board had a whitish/gray substance noted in between the grooved areas. During this same observation, the Recovery Room had seven (7) computer documentation portable stations that had a discolored grayish/white sticky substance noted on the outer edges of the computer stations. Further observation revealed the Cysto Room #1 and Cysto Room #2 had a black stool cushion seat that had two (2) strips of about four (4) inch satin tape that were placed a "cross sign" across the top of the cushion area. There was a blackish/gray discoloration noted on the outer edges on each of the two four inch strips of satin tape. There was a grayish sticky substance noted in the areas that were not covered by the 2 pieces of satin tape on the side of the cushion. Further observation of Cysto Room #2 revealed the black stool had the stool's front edge covered with about seven (7) layers of satin tape. The satin tape's outer edges were grayish/black in color. During this same observation, the Same Day Surgery, room "a" had the plastic pillow case with three (3) brown areas. The head and foot intravenous poles red adjustment knob area was covered with a piece of tape with the outer edges that were black in color. The mattress area that touched the bed frame was covered with a white substance. The white ceramic floor tile had a blackish/gray discoloration noted in the grooved areas of the tile. The plastic pillow case cover had three (3) orange spots on it. During this same tour and observation of the Surgery Department, S12 Surgery Director, S4 Infection Control Coordinator, and S15 Housekeeping Director verified the above findings.

Review of the policy titled, "Environmental Operating Room Sanitation", Effective Date: 6/94, Revision Date: 7/00, with no policy number or reviewed date, read, "Operating Room personnel will have knowledge of required sanitation requirements and notify the Operating Room supervisor of any unacceptable conditions. A clean environment for the surgical patient, personnel and equipment. All items coming in contact with the patient are considered to be contaminated. Between cases cleaning should include damp wiping of spillage (organic debris) from equipment including stools, damp wiping of intravenous solution poles. Each area is terminally cleaned that includes the thorough cleaning of furniture and equipment used in a germicidal solution and friction. Floors are scrubbed/mopped".

The policy titled, "Infection Control Coordinator", IC4, Effective Date of 9/88, Revision Date of 9/98, Review Date of 2/03, read as follows, "It is the responsibility of the Equipment Technician and Environmental Service to clean and disinfect the designated equipment. All used equipment is considered contaminated regardless of what patient used it".

Based on record reviews and interviews, the chief executive officer, the medical staff, and the director of nursing:
1) failed to ensure that the hospital-wide quality assurance program addressed the current non-compliance identified by the Quality Program of the nursing department directors incomplete and inaccurate reporting of the "Tracer Audit" forms implemented by the team to assess, track, and analyze the nursing staffs compliance and/or non-compliance to initiate and follow physicians orders for isolation precautions for 8 patients identified with positive Methicillin Resistant Staphylococcus Aureus (MRSA) cultures from June through September of 2010. This non-compliance continued from 5/12/10 through 9/28/10; and
2) failed to be responsible for the implementation of corrective action plans for the continued non-compliance of each of the nursing department heads to complete the "Tracer Audit" forms as ordered by the attending physician's for isolation precautions and/or as per "Isolation Precaution" policy. This continued non-compliance was since 5/12/10. Findings:

Review of the list of patient's with positive MRSA cultures from June through September of 2010 was presented on 9/23/10 at 12:40 pm. Further review of the patients with positive MRSA cultures revealed there were a total of eight (8) patients that had positive MRSA cultures. There were 4 patients identified for the month of June, 2 patients identified for the month of July, 1 patient identified for the month of August and 1 patient identified for the month of September.

The "Infection Control Survey , Nursing Services, ICU/CCU" forms completed by the Infection Control Coordinator, (S4) from 5/12/10 through 8/4/10 were reviewed. Further review of the Nursing Services Survey forms revealed the "Isolation Precautions" policy was "not routinely being followed by the nursing staff". Further review of the "Infection Control Survey" forms revealed there was no documented evidence that the "Tracer Audit" forms were being completed by the nursing department heads from May through August of 2010. There was no documented evidence of the "Tracer Audit" forms were completed and returned from August through September of 2010 presented during the survey from 9/24/10 to 9/28/10. Further review of the "Infection Control Survey, Nursing Services" forms completed by S4 revealed there was no documented evidence of the data collected to assess and evaluate whether the nursing staff in each department in the hospital was compliant with initiating and/or following the isolation precaution monitoring as per policy and/or as ordered by the physician from 5/12/10 through 9/28/10 presented during the survey from 9/24/10 to 9/28/10.

Review of the " Performance Improvement Meeting Minutes " held on 7/30/10 revealed Quality Director (S3), Performance Improvement (S5) and Infection Control Coordinator (S4) reported that the nursing staff were not initiating and implementing the contact isolation precautions as per the "Isolation Precautions" policy and/or as ordered by the attending physicians from 5/12/10 to 7/30/10. Further review of the meeting minutes revealed there was non-compliance documented that each nursing department directors had not completed the "Tracer Audit" forms that were implemented by the quality program to evaluate and assess the nurses compliance and/or non-compliance with the isolation precautions as per the "Isolation Precaution" policy and/or as ordered by the attending physicians from 5/12/10 to 7/30/10.

There was no documented evidence that the "Tracer Audit" forms were completed and returned by each nursing department director from 7/30/10 through 9/28/10 presented during the survey from 9/24/10 through 9/28/10.

In face-to-face interviews conducted on 9/28/10 at 2:00 pm, Quality Director (S3), Performance Improvement Director (S5), and Infection Control Coordinator (S4) all indicated the hospital's Quality Program identified on 5/12/10 that the nursing staff in each department of the hospital were not following the "Isolation Precaution" policy for all patients suspected of an infection to be placed on contact isolation precautions. They all reported that the nurses were identified not following the attending physician's orders for patients to be on contact isolation precautions since 5/12/10. They all indicated that the nursing director, (S2) and medical staff were notified of the nursing staff's non-compliance with the "Isolation Precautions" policy and/or physician's contact isolation precaution orders when the Quality Program identified the problem on May 12, 2010. They all agreed the "Tracer Audit" form was implemented as a corrective action plan tool that would be used by the program to track, evaluate, and assess the nurses compliance and/or non-compliance with the "Isolation Precaution" policy and/or physicians orders for contact isolation precautions since 5/12/10 . They all reported that each of the nursing departments directors did not complete and return the "Tracer Audit" forms (corrective action plan tool) implemented since 5/12/10 that would be used to evaluate, track, analyze and assess the nurses compliance or non-compliance with the isolation precautions as per the "Isolation Precaution" policy and/or as ordered by the attending physicians for contact isolation precaution since May 12, 2010. They all indicated the Director of Nursing (DON) and Medical Staff had knowledge that the nursing department heads were not completing and returning the "Tracer Audit" forms to the quality program team since 5/12/10. They all reported that the Medical Staff was notified a second time that the nursing directors had continued non-compliance with completing and returning the "Tracer Audit" forms from May through July at the last, Performance Improvement Meeting held on July 30, 2010. They all indicated that there was current, non-compliance from each nursing department directors/heads not completing and returning the "Tracer Audit" forms implemented by the program to evaluate, track, analyze and assess the nurses compliance and/or non-compliance with contact isolation precautions as per the policy and/or as ordered by the attending physicians. They all reported there was incomplete data collected to evaluate and assess the nursing staffs compliance with initiating the isolation precaution policy when patients were suspected to have an infection and/or following physicians orders for isolation precautions since May 12, 2010. They all indicated the program could not evaluate the patients care provided by the nursing staff in the hospital with incomplete and inaccurate "Tracer Audit" forms since 5/12/10. They all reported the Medical Staff did not implement a revised corrective action plan as needed for the nursing department heads and/or nursing staffs current non-compliance that was identified since May 12,2010.

During a face-to-face interview on 09/28/10 at 3:00 pm, the DON (S2) indicated the facility had an ongoing problem with the nursing staff not implementing the isolation precaution policy and/or following physicians orders for isolation precaution monitoring that was identified by the Quality Program Team, (S3, Quality Director, S5, Performance Improvement Director, and S4, Infection Control Coordinator) on 5/12/10. She further indicated there was current non-compliance from each nursing department director to complete and return the "Tracer Audit" form/tool implemented by the quality team on 5/12/10. The DON reported that the Medical Staff was notified of the nursing department heads continued non-compliance with completing the " Tracer Audit " forms as well as the nursing staffs current non-compliance with initiating and following the isolation precaution policy and/or physicians orders since 5/12/10. She indicated the Medical Staff had not taken actions for the nursing department heads continued non-compliance with completing and returning the " Tracer Audit " forms to the infection control coordinator (S4) and/or the nursing staffs current non-compliance with the isolation precaution monitoring since 5/12/10. S2 further indicated that the Medical Staff did not address the nursing problems identified by the infection control officer (S4) since 5/12/10. The DON indicated the Medical Staff did not monitor and assess the effectiveness of the corrective action plan, "Tracer Audit" forms implemented by the infection control officer (S4) on 5/12/10. The DON further indicated the Medical Staff did not implement a revised corrective action plan for the current non-compliance with the nursing department heads to complete and return the "Tracer Audit" forms and/or nursing staff not initiating and/or following the isolation precaution monitoring as indicated per policy or physicians orders since 5/12/10. The DON further indicated the Medical Staff had not implemented a revised corrective action plan as needed for the nursing department heads and/or nursing staffs current non-compliance that was identified since May 12,2010.

The policy titled, " Isolation, Initiating " , Number: IC.5, Effective date of 9/92, Review date of 2/1008, Reference CDC Guidelines for Isolation Precautions June, 2007, pages 1 to 2, read in part, " All hospital employees are responsible for initiating and maintaining isolation with the assistance of the attending physician. Infection Control is responsible to assist with the initiating and maintaining of isolation. Isolation is used to prevent the spread of infection from patient to patient, patient to physician, nurse, attendant and/or visitors and to prevent reinfection. All patients who have a diagnosis of a communicable diseases or there is a suspicion of the presence of communicable disease, shall be placed in isolation for prevention of spread of disease. When patient is admitted with a communicable disease or contagious disease, or suspicion of a communicable disease, and the physician has not ordered isolation precautions, the nurse assigned to the patient must institute precautions immediately. The nurse must notify the attending physician as soon as possible, and write "isolation per hospital protocol" on the physician order sheet. The nurse must also document when isolation is being enforced on a day to day basis. The Infection Control Team shall be triggered for patients admitted with a communicable disease or contagious disease or suspicion of a communicable disease. When lab work reports suggest a contagious disease, call the physician and request an order for isolation and trigger Infection Control".

Review of the hospital Bylaws, with a revised date of 9/2007, Article IX INFECTION CONTROL, revealed in part, "All nursing units shall follow the standard procedure for isolation as outlined in the Infection Control Manual for Isolation Precautions in Hospitals (CDC Guidelines). Any patient with a known or suspected communicable disease or infection shall be isolated. The attending physician will be notified. The Infection Control Coordinator in consult with the Infection Control Team shall be empowered to order appropriate isolation procedures or epidemiologic investigations as required. When a series of infections, including post-operative infections occur and infections of epidemic proportion, the Infection Control Coordinator in consult with the Infection Control Team shall initiate procedures necessary to investigate and prevent further spread of infection. All Medical Staff members shall be required to comply with appropriate infectious disease policies and procedures of the hospital".

Based on observations and interviews the hospital failed to ensure the hospital policy and procedure was followed by failing to maintain a sanitary hospital environment by having dirty patient equipment (computer keyboards, omnicell machines, computer documentation stations, stools, intravenous poles, mattress, bathroom floor tile, plastic pillow case) available for patient usage in Operating Room #2, Pre-Operative area, Recovery Room area, Cysto Room "a", and Same Day Surgery. Findings:

A tour of the Surgery Department was conducted from 2:00 pm through 4:00 pm on 9/27/10 with the Surgery Director (S12) and Infection Control Coordinator (S4). During this same observation, Operating Room #2 (OR#2) had a computer key board that was covered with plastic. This plastic had a whitish/gray substance inside the grooved areas of the key board. Further observation revealed, the Pre-Operative Area had five (5) omnicell machines with a plastic covering over the computer's key board. This clear plastic coating on the key board had a whitish/gray substance noted in between the grooved areas. During this same observation, the Recovery Room had seven (7) computer documentation portable stations that had a discolored grayish/white sticky substance noted on the outer edges of the computer stations. Further observation revealed the Cysto Room #1 and Cysto Room #2 had a black stool cushion seat that had two (2) strips of about four (4) inch satin tape that were placed a "cross sign" across the top of the cushion area. There was a blackish/gray discoloration noted on the outer edges on each of the two four inch strips of satin tape. There was a grayish sticky substance noted in the areas that were not covered by the 2 pieces of satin tape on the side of the cushion. Further observation of Cysto Room #2 revealed the black stool had the stool's front edge covered with about seven (7) layers of satin tape. The satin tape's outer edges were grayish/black in color. During this same observation, the Same Day Surgery, room "a" had the plastic pillow case with three (3) brown areas. The head and foot intravenous poles red adjustment knob area was covered with a piece of tape with the outer edges that were black in color. The mattress area that touched the bed frame was covered with a white substance. The white ceramic floor tile had a blackish/gray discoloration noted in the grooved areas of the tile. The plastic pillow case cover had three (3) orange spots on it. During this same tour and observation of the Surgery Department, S12 Surgery Director, S4 Infection Control Coordinator, and S15 Housekeeping Director verified the above findings.

Review of the policy titled, "Environmental Operating Room Sanitation", Effective Date: 6/94, Revision Date: 7/00, with no policy number or reviewed date, read, "Operating Room personnel will have knowledge of required sanitation requirements and notify the Operating Room supervisor of any unacceptable conditions. A clean environment for the surgical patient, personnel and equipment. All items coming in contact with the patient are considered to be contaminated. Between cases cleaning should include damp wiping of spillage (organic debris) from equipment including stools, damp wiping of intravenous solution poles. Each area is terminally cleaned that includes the thorough cleaning of furniture and equipment used in a germicidal solution and friction. Floors are scrubbed/mopped".

The policy titled, "Infection Control Coordinator", IC4, Effective Date of 9/88, Revision Date of 9/98, Review Date of 2/03, read as follows, "It is the responsibility of the Equipment Technician and Environmental Service to clean and disinfect the designated equipment. All used equipment is considered contaminated regardless of what patient used it".