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Based on policy review, medical record review and staff interviews, the hospital failed to ensure their infection control policies and procedures regarding contact precautions and cohorting of patients were followed for 5 of 30 patients requiring isolation (#35, #5, #34, #21 and #15).

The findings include:

Review of the hospital's "Infection Prevention and Control Practices" revised May 2010 revealed "Purpose: To provide guidelines for controlling the spread of antibiotic-resistant organisms, including but not limited to Methicillin-resistant Staphylococcus Aureus (MRSA), Vancomycin-resistant Enterococci (VRE).... Policy: The following procedure will be followed in order to prevent cross-contamination to other patients, employees and the community. It will be followed on all patients with known history, known or suspected infection or colonization with multi-drug resistant organisms.... Procedure: Definitions: Multi-Drug Resistant Organism (MDRO)- Microorganisms, predominantly bacteria that are resistant to one or more classes of anti-microbial agents and deserve special attention within the healthcare facility.... 1. All patients with known MDRO, or who have previously been identified as colonized with MDROs, will be placed on Contact Precautions.... 3. Patient Placement: ...a. In deciding where to place a patient, the following should be followed: When single-patient rooms are available, assign priority for these rooms for patients with known or suspected MDRO colonization or infection. When single patient rooms are not available, cohort with patient with same MDRO organism...."

1. Closed record review on 10/28/2010 of Patient #35 revealed a 52 year-old male admitted 04/20/2010 as a transfer from another hospital for ongoing therapy and rehabilitation. Record review revealed the patient had multiple wounds of the sacrum, legs and thighs upon admission. Review of the physician's history and physical dated 04/21/2010 recorded the patient had a history of positive MRSA upon admission. Review of nursing notes dated 05/03/2010 at 1038 recorded the patient was on "standard precautions." Nursing notes dated 05/06/2010 at 1417 recorded "MRSA sacral wound." Further review revealed the patient was transferred to room #207-1 (three bed patient room) on 06/15/2010 at 1605. Review revealed Patient #35 was placed in room #207 with Patient #5. Review of Patient #5's medical record revealed Patient #5 had no identified communicable disease on 06/15/2010 when the patients were placed in the same room. Review revealed Patient #34 transferred into room #207 on 06/17/2010. Review of Patient #34's medical record revealed Patient #34 had no identified communicable disease on 06/17/2010 when the patients were placed in the same room. Record review of Patient #35 revealed a physician's order dated 06/21/2010 at 1451 for "contact precautions: roommate MDRO 6/21/10 sputum." Record review revealed the patient remained in room #207 until discharge to a skilled nursing facility on 06/25/2010.

Interview on 10/28/2010 at 1125 with the facility's Infection Control Officer confirmed that Patient #35 had a history of positive MRSA and was not placed on contact precautions. Interview revealed the three patients were placed in a room together and two of the three patients did not have an identified communicable infection. Interview confirmed facility staff failed to cohort patients with similar organisms as the facility policy describes. The staff member stated "Until Tuesday, 10/26/2010 our staff were trained that MRSA patients do not have to be placed on contact precautions. We re-trained our staff on Tuesday that all patients with positive MRSA should be on contact precautions." The staff member confirmed that the facility policy required patients with MRSA to be placed on contact precautions. Interview confirmed the facility staff failed to follow the infection control policy.

2. Open record review of Patient #5 revealed a 46 year-old male admitted 06/11/2010 as a transfer from another hospital for ongoing therapy and rehabilitation. Record review revealed the patient had a history of traumatic brain injury with encephalopathy and subdural hematoma. Record review revealed the patient had no identified communicable disease upon admission and was placed on "standard precautions." Record review revealed the patient was transferred to room #207-3 (three bed patient room) on 06/15/2010 at 1600. Review revealed Patient #5 was placed in room #207 with Patient #35. Review of Patient #35's medical record revealed Patient #35 had a history of MRSA and was not on contact precautions when the patients were placed in the same room. Review revealed Patient #34 transferred into room #207 on 06/17/2010. Review of Patient #34's medical record revealed Patient #34 had no identified communicable disease on 06/17/2010 when the patients were placed in the same room. Record review of Patient #5 revealed a physician's order dated 06/21/2010 at 1453 for "contact precautions: roommate MDRO 6/21/10 sputum." Review of Patient #5's lab culture reports revealed the patient had a positive MDRO urine culture reported on 07/26/2010 at 1230.

Interview on 10/28/2010 at 1125 with the facility's Infection Control Officer confirmed that Patient #35 had a history of positive MRSA and was not placed on contact precautions. Interview revealed the three patients were placed in a room together and two of the three patients did not have an identified communicable infection. Interview confirmed facility staff failed to cohort patients with similar organisms as the facility policy describes. The staff member stated "Until Tuesday, 10/26/2010 our staff were trained that MRSA patients do not have to be placed on contact precautions. We re-trained our staff on Tuesday that all patients with positive MRSA should be on contact precautions." The staff member confirmed that the facility policy required patients with MRSA to be placed on contact precautions. Interview confirmed the facility staff failed to follow the infection control policy.

3. Open record review of Patient #34 revealed a 51 year-old male admitted 06/10/2010 as a transfer from another hospital for respiratory failure management. Record review revealed the patient had a history of ventilator dependant respiratory failure and pneumonia. Record review revealed the patient had no identified communicable disease upon admission and was placed on "standard precautions." Record review revealed the patient was transferred to room #207-3 (three bed patient room) on 06/17/2010 at 0839. Review revealed Patient #34 was placed in room #207 with Patients #35 and #5. Review of Patient #35's medical record revealed Patient #35 had a history of MRSA and was not on contact precautions when the patients were placed in the same room. Review of Patient #5's medical record revealed Patient #5 had no identified communicable disease on 06/17/2010 when the patients were placed in the same room. Review of Patient #34's lab culture reports revealed the patient had a positive MDRO tracheal aspirate culture reported on 06/21/2010 at 1107. Record review of Patient #34 revealed a physician's order dated 06/21/2010 at 1141 for "contact precautions: MDRO sputum."

Interview on 10/28/2010 at 1125 with the facility's Infection Control Officer confirmed that Patient #35 had a history of positive MRSA and was not placed on contact precautions. Interview revealed the three patients were placed in a room together and two of the three patients did not have an identified communicable infection. Interview confirmed facility staff failed to cohort patients with similar organisms as the facility policy describes. The staff member stated "Until Tuesday, 10/26/2010 our staff were trained that MRSA patients do not have to be placed on contact precautions. We re-trained our staff on Tuesday that all patients with positive MRSA should be on contact precautions." The staff member confirmed that the facility policy required patients with MRSA to be placed on contact precautions. Interview confirmed the facility staff failed to follow the infection control policy.

4. Closed record review on 10/27/2010 of Patient #21 revealed a 60 year-old female admitted 07/29/2010 as a transfer from another hospital for continuation of ongoing therapy and rehabilitation. Review of the physician's history and physical dictated 07/29/2010 revealed the patient underwent a cervical decompression on 06/12/2010 and an incision and drainage of the surgical wound site with application of a wound vac on 06/24/2010 at another facility. Notes recorded the patient developed pain and fever and was found to have a MRSA cervical wound infection prior to transfer. Review of nursing admission notes dated 07/30/2010 at 0024 revealed the patient had "MRSA spinal wound infection" and was placed on "Standard Precautions." Review of the record revealed the patient was discharged to a skilled nursing facility on 08/25/2010. Further record revealed no evidence the patient was placed on contact precautions during her admission.

Interview on 10/28/2010 at 1125 with the facility's Infection Control Officer confirmed that the patient was not placed on contact precautions. The staff member stated "Until Tuesday, 10/26/2010 our staff were trained that MRSA patients do not have to be placed on contact precautions. We re-trained our staff on Tuesday that all patients with positive MRSA should be on contact precautions." The staff member confirmed that the facility policy required patients with MRSA to be placed on contact precautions. Interview confirmed the facility staff failed to follow the infection control policy.



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5. Closed record review on 10/27/2010 of Patient #15 revealed a 67 year-old female admitted 07/27/2010 at 1008, as a transfer from another hospital for Rehabilitation and weaning from a Ventilator. Review of the patient medical record revealed the patient was admitted into a private room with MRSA in the blood and sputum and put on Standard Contact precautions. Further review of the patient medical record showed on 08/11/2010 the patient was then put on contact isolation precautions due to MDRO, of Klebsiella and Pneumonia. The patient eventually expired on 09/06/2010.

Interview on 10/28/2010 at 1400 with the facility's Infection Control Officer confirmed that the patient was not placed on contact precautions upon admission. The staff member stated "Until Tuesday, 10/26/2010 our staff were trained that MRSA patients do not have to be placed on contact precautions. We re-trained our staff on Tuesday that all patients with positive MRSA should be on contact precautions." The staff member confirmed that the facility policy required patients with MRSA to be placed on contact precautions. Interview confirmed the facility staff failed to follow the infection control policy.