HospitalInspections.org

Based on facility policy review, medical record review, observation, and interview, the facility failed to follow infection control guidelines for 1 patient (#7) of 6 patients residents reviewed for isolation.

The findings included:

Review of facility policy Multi Drug Resistant Organisms revised 7/2012, revealed "...contact precautions consist of...wearing gloves...during the course of providing care for a patient...if the patient is transported out of the room, ensure that precautions are maintained to minimize the risk of transmission of microorganisms to other patients and contamination of environmental services or equipment..."

Medical record review of Patient #7 revealed the patient was admitted to the facility 11/10/16 with a diagnosis of Gastro-Intestinal Bleed. Further review revealed he tested positive for Vancomycin-Resistant Enterococci (VRE), a strain of "superbugs" resistant to the antibiotic Vancomycin.

Observation and interview with the Chief Nursing Officer (CNO) on 11/15/16 at 3:30 PM, in the physical therapy/occupational therapy gym, revealed Patient #7 was sitting at a table doing for therapy. Continued observation revealed the patient was wearing a cervical collar and regular clothing Further observation revealed a therapy student was assisting the patient with therapy without wearing protective gloves. Interview with the CNO revealed patients in contact isolation were to have a green charm on their patient bracelet and were to wear yellow gowns. Continued interview with the CNO confirmed the patient did not have the green charm on his bracelet and the patient was not wearing a yellow gown.

Interview with Occupation Therapist (OT) #1 on 11/15/16 at 3:30 PM, in the therapy gym, confirmed she did not know Patient #7 was in contact isolation. Continued interview confirmed the OT was not wearing protective gloves while therapy was provided to the patient. Further interview confirmed the patient was not wearing a yellow gown and did not have a green charm on the bracelet to indicate he was in contact isolation.