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NEXUS SPECIALTY HOSPITAL THE WOODLANDS
INFECTION CONTROL PROGRAM
Tag No.: A0749
Based on observation, interview and record review the hospital failed to ensure that staff adhered to isolation precautions for 3 of 3 patients on isolation precautions. (Patient ID#'s 3, 4 and 5)
Findings include:
Observation 3/13/14 at 9 a.m. revealed that patient ID# 4 had a sign on the door that read "Contact Isolation." A nurse (ID# 55) was observed exiting the patient room. The nurse took off her gloves and did not wash her hands. The nurse immediately went to the front desk and answered the telephone.
The medical record for patient ID# 4 revealed the patient was on contact isolation due to E-coli in the urine.
Record review of a policy titled "Hand Hygiene" dated June 2011 stated "Hands should be sanitized using the hospital approved waterless hand antiseptic agent in the following situations: After removing gloves..."
Further observation 3/13/14 at 10:30 a.m. revealed a patient in room 315 (Patient ID# 3) had a sign on the door that read "Contact Isolation." A patient care technician (ID# 57) was observed positioning the patient in a wheelchair. The technician was wearing gloves. The technician then went across the hall and entered another patient room (Patient ID# 5) without removing and washing his hands. The technician proceeded to adjust the head-rest on the wheelchair for patient ID# 5 with the same pair of gloves he used to assist the previous patient (Patient ID# 3) on isolation.
A sign on the door of patient ID# 5 read "Contact Isolation." The medical record for patient ID# 5 revealed the patient was on contact isolation due to MRSA of the sputum.
At this time, a speech therapist (ID# 58) was observed in patient ID# 5's room sitting on the bed. The speech therapist was not wearing a gown or gloves. Patient ID# 5 was on contact isolation. The sign outside the door read "Gown required and gloves required..."
The Infection Control Practitioner (ID# 56) acknowledged 3/13/14 at 1 p.m. the hospital staff needed more in-servicing as it relates to isolation precautions and hand washing.