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Based on observation, interview and record review the facility failed to develop, implement and enforce infection control practices in order to decrease the spreading of infectious diseases.

Findings include:

Review of the facility provided Transmission-Based Precautions Policy (dated 06/2018) reflected, "...Transmission-Based Precautions are for patients with documented or suspected infection or colonization with epidemiologically important pathogens for which additional precautions are needed to prevent transmission.... C.) Items are to be cleaned in the patient's room, then brought out and left to air dry.... 5. If a patient must leave his or her room ... ensure that precautions are maintained during the transfer, etc.... c.) Have patient wear clean clothing or a clean patient gown...." The policy did not include instructions on the transporting of contaminated beds, furnishings and personal belongings.

During an interview on the afternoon of 1/07/19, Staff #4, Infection Control Preventionist stated, "Patient #3 is on contact precautions for MRSA (Methicillin-resistant Staphylococcus aureus) and VRE (Vancomycin-resistant Enterococci)."

An observation on the facilities medical surgical unit on the morning of 1/07/19 revealed Patient #3 sitting in the hallway. The patient's bedside table and over bed table were also in the hall. The patient's personal belongings were sitting on the tables. The patient was not wearing an isolation gown. Staff #1 , RN was observed removing the contact isolation sign from the door frame and moving it over to the room Patient #3 was sitting in front of, leaving the dirty room unmarked as being contaminated. Staff #1 transported Patient #3 into the new room and came out of the room wearing the contaminated gown and gloves.
Further observation revealed the facility's Hoyer transfer lift was taken into Patient #3's room. The staff came out of the room with the contaminated Hoyer lift and wiped the controls clean. The Hoyer lifts rails which were connected to the Patient's sling were not wiped clean.

During a conversation on the morning of 1/07/19, Staff #1 informed Staff #7, Nurse Manager, that the patient was being moved to a new room and confirmed the tables and bedside table had been removed from the dirty room. Staff #1 did not demonstrate a knowledge of the correct infection prevention practices and policies. Staff #1 stated the patient had come back from the therapy department and that the therapist had transported the patient out of the room.

During a conversation on the morning of 1/07/19, on the medical surgical unit, Staff #7, Nurse Manager stated, "...The patient needs to be in an isolation gown when out of the room...." and confirmed the contaminated bedside table, belongings and over-bed table should not be in the hallway.