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Based on observation, interview and policy review, the facility failed to ensure isolation precautions were followed. (A749). The hospital census was 19.

Based on medical record review, facility policy review, and staff interview, the facility failed to ensure staff followed the current facility policy related to colostomy care. This affected Patient #1. The facility census was 19.

Findings include:

Review of the medical record of Patient #1 revealed the patient was admitted to the facility on 06/21/23 at 11:10 AM. According to the Admission Clinical Overview, the patient presented to an outside hospital on 05/08/23 with complaints of abdominal pain and nausea. She was found to have a hyperenhancement of the rectosigmoid colon which was concerning for diverticulitis. On 05/12/23, the patient underwent an exploratory laparotomy, rectal sigmoidectomy, and end colostomy creation. Her hospital course was complicated by hepatic dysfunction causing encephalopathy. The patient was also found to have an acute kidney injury likely secondary to ischemic septic acute tubular necrosis. The patient required hemodialysis. After multiple unsuccessful attempts to extubate the patient, she required a tracheostomy on 05/31/23. The primary reason for the patient's admission to the facility was acute respiratory failure requiring pulmonary consult and management, 24 hour respiratory services to provide ventilatory support, management, and weaning.

Patient #1 was ordered to receive colostomy care. Review of the colostomy care flow sheet revealed on 06/21/23 at 11:46 PM, the patient's colostomy pouch was emptied for 100 mL. The assessment noted the peristomal abdomen was firm, stoma color pink, and peristomal skin intact. Assessments and output continued every shift. On 06/23/23 at 7:15 PM. output from the patient's colostomy was 450 mL. The flow sheet revealed staff nurses provided colostomy care every shift on 06/24/23-06/28/23 as required. On 06/29/23 the colostomy flow sheet lacked documentation the colostomy site was assessed or bag emptied as required by facility protocol. Documentation of colostomy care was noted on 06/30/23 at 8:30 AM. Again, there was no documentation of colostomy care during night shift hours on 06/30/23. The colostomy flow sheet lacked documentation the colostomy site was assessed or bag emptied on 07/01/23, 07/02/23, 07/03/23, or 07/04/23. Documentation of colostomy care was noted on 07/05/23 and 07/06/23. However, on 07/07/23, 07/08/23, and 07/09/23, the colostomy flow sheet again lacked documentation of any colostomy care. The flow sheet lacked documentation colostomy care was provided on 07/12/23, 07/14/23, and 07/21/23 during day shift or night shift hours.

During interview on 09/07/23 at 5:00 PM, Staff H and Staff Y confirmed that the medical record lacked documentation of colostomy care at least every shift or every 12 hours as required.

The facility policy titled "Interdisciplinary Assessment and Re-Assessment", effective June 2022, documented an admission assessment is performed by an RN and recorded in the patient's medical record within 12 hours of admission. This assessment is based upon actual observation, patient/family interview, patient medical records accompanying the patient from the referral facility. The RN admission assessment data is a primary source for the RN to determine and prioritize nursing care needs specific to the patient. Patients are re-evaluated by a licensed nurse at a minimum every 12 hour shift.

Based on observation, interview and policy review, the facility failed to ensure staff followed infection control precautions when entering rooms of patients that were under isolation precautions. This affected two patients and five patient rooms. The hospital census was 19.

Findings include:

During tour on 09/05/23 at 5:30 PM with Staff Y, Staff S from the Dietary Department was walking in the hall and wearing a disposable glove on his left hand only. He was carrying a dinner tray. Stopping in front of room #2005, a room designated with a contact precaution sign, Staff S placed the tray on the isolation cart outside of the room. He donned a disposable gown, picked up the dinner tray, knocked on the door, and opened the door using his right hand, the hand without a glove. Staff S walked in the room and walked out of the room seconds later without the tray indicating that the tray was delivered to the patient in the room. Staff S was wearing the disposable gown and still wearing the disposable glove on his left hand as he walked out of the room. Standing outside of the room, Staff S removed the disposable gown and disposed of the gown in the garbage can of an empty room. The disposable glove remained on the left hand of Staff S. Staff S was not observed to remove the glove on his left hand nor perform hand hygiene.

During tour on 09/05/23, Staff T was observed in the doorway of room #2031. Staff T was heard asking the patient if he/she was okay from just inside the doorway. Staff T asked the patient if she could retrieve the dinner tray. The staff member walked into the room, retrieved the dinner tray, and walked out. Signage on the outside of the door revealed the patient was in contact isolation. Staff T was not wearing a disposable gown or gloves nor did she use hand sanitizer after walking out of the room with the tray. This was confirmed with Staff Y during the tour.

During interview on 09/06/23 at 11:15 AM, Staff Y verified the above observations.

The facility policy titled "Terminal Cleaning of a Patient Room", effective June 2022, documented patient rooms are thoroughly cleaned and disinfected following termination of occupancy by transfer or discharge. Transmission-based precautions are observed by the environmental services staff. The policy stated that the facility will ensure terminal cleaning is completed before another patient is admitted or transferred to a room. The rooms are cleaned with Environmental Protection Agency approved disinfectants and in a manner to reduce risks of disease transmission among patients. Terminal cleaning of a patient room includes window sills, furniture, bed, bathroom (toilet, handrail, sink, shower/tub, and bathroom fixtures), inside bedside drawers and over-bed drawer, light switches, door handles, floor, etc. Environmental staff members are instructed to high dust and wipe down all ceilings and walls, light fixtures, vents, and to be sure to wipe/dust everything shoulder high and above. Clean the bathroom area with approved cleaners including toilet seat, toilet flush handle, tissue roll holder, base of toilet, bathroom handrails, bathroom sink, light switch, doorknobs, and bathtub or shower, and towel rack. Staff members were further instructed to clean equipment in room using disinfectant in room before leaving the room.

The facility policy titled "Transmission-Based Precautions", effective June 2022, documented transmission-based precautions are for patients with documented or suspected infection or colonization with pathogens for which additional precautions are needed to prevent transmission. Contact precautions is a method designed to reduce the risk of transmission of microorganisms by direct or 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. Increased risks include but are not limited to: presence of excessive drainage, fecal incontinence, or other discharges from the body suggesting an increased potential for extensive environmental contamination and risk for transmission. If an infection appears to be present the recommended appropriate transmission based precautions should be executed at that time. Post the appropriate precaution signage visible outside patient room. Notify family of the reason for initiation of the infection precautions and the expectations that go along with it. The patient's caregivers should educate patients and visitors about the patient's status, and prevention measures required (hand hygiene and PPE). Staff should perform hand hygiene and don PPE when entering patient room with known infection.

The facility policy titled "Donning an Doffing Personal Protective Equipment", effective June 2022, documented PPE is utilized to reduce the risk of transmission and/or prevent the transmission of pathogenic organisms from patient to healthcare worker and from healthcare worker to patient. The policy of the facility is to utilize PPE when there is a potential for contamination. PPE will be donned upon entering the patient room. PPE will be doffed upon exiting the patient room in a manner to prevent cross-contamination. The procedure for donning PPE was discussed. The policy instructed staff that the outside of gloves are considered contaminated.