HospitalInspections.org

36293

Based on observation, policy/procedure review and interviews, the hospital failed to have a system in place to prevent and control the transmission of infections by failing to display isolation precaution signage on the doorways of patient's with known infectious diseases. This deficient practice was evidenced by the hospital failing to have visible signage on the doorways for 4 of 4 patients with known infectious disease.

Findings:

Observation 04/14/2021 at 8:40 a.m. revealed a wall board patient list in the nurse's station with isolation precautions denoted for patient R1 and patient R2.

Observation 04/14/2021 at 08:45 a.m. revealed an input and output log hanging from a hook on the patient R1 and R2's doors. Further investigation revealed an isolation sign completely obscured and underneath the input and output log.

Observation 04/14/2021 at 08:50 the COVID unit's hallway entryway failed to reveal isolation precaution signage posted outside of the unit. The unit was inside a hallway sealed off with a thick opaque plastic which had a zippered entry way. Surveyor did not enter the unit.

Review of the hospital's Policy Procedure R18.09, titled "Guidelines for Transmission Based Isolation Precautions revealed in part: B. In order to reduce the risk of transmission of microorganisms, Contact, Droplet, and Airborne Precautions will be routinely practiced by all hospital personnel whenever indicated. The following strategies, as recommended by the Centers for Disease Control must be adhered to in order to protect patients and personnel. C. Signs indication the type of precautions will be clear and visible at the entry to the known or suspected infected patient's room.

Interview 04/14/2021 at 9:00 a.m., S4RN acknowledged the isolation signage for patient's R1 and R2 was covered with the input and output log and stated the signs should have been visible and not covered. S4RN continued to state the signage is placed on the individual patient rooms within the COVID unit and not on the entryway.
Interview 04/14/2021 at 3:00 p.m., S3PTA, who was inside the COVID unit, spoke with the surveyor though the plastic enclosure and to direct question stated there were no contact/droplet precaution signage on patient R3 and R4's doorways.

Telephone Interview 04/14/2021 at 3:45 p.m., S5IC stated all patients with isolation precautions should have a sign indicating the type of precautions required and the sign should always be visible. She continued to state the patients located in the COVID unit should have signs on the entry of the patient's individual rooms.