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Based on observation, interview and record review the facility's infection control officer failed to monitor for compliance of the facility's isolation policies for infectious diseases.

Findings Include:

Review of Patient #1's medical records reflected a 56-year-old female, located in room #213, admitted on 12/5/18 for osteomyelitis (bone infection) to the right below knee amputation. The bone cultures conducted at the sending hospital revealed the patient was positive for MRSA (Methicillin-resistant Staphylococcus aureus) and septicemia ESBL, (Gram-negative bacteria extended-spectrum beta-lactamases) significant because, when they are produced by the germs (bacteria), they can make the bacteria resistant to certain commonly used antibiotic medicines. The patient had orders to remain on the antibiotic Vancomycin until 1/1/2019.

During a tour on 12/27/18 of the facility inpatient unit revealed the Patient room #213 did not have a sign designating the room as requiring Contact Isolation Precautions.

During an interview on the afternoon of 12/27/18, in the facility conference room, Staff #4, Infection control nurse confirmed the wound was positive for ESBL and stated, "... She (Patient #1) should be on Isolation... we don't isolate for MRSA or VRE (Vancomycin Resistant Enterococci) we use standard precautions."

Review of the facility provided Standard, Transmission Based and Neutropenic Precautions and Discontinuation of Precautions (last review date 2/18) reflected, "... Identifying Potentially Infectious Patients a. Facility staff remain alert for any patient arriving with symptoms of an active infection (e.g., diarrhea, rash, respiratory symptoms, draining wounds or skin lesions).... Contact Precautions Applies to patients with any of the following active infections and/or conditions: Extended Spectrum Beta Lactamase (ESBL) producing enterobacteriaceae... PPE use: Wear gloves and gown when in patient room regardless of anticipated contact with patient or patient's surroundings.... MDR (multi-drug resistant) Gram negative organisms will remain on isolation for the duration for the duration [sic] of their stay...."