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Based on observations, interviews and policy review, the facility infection preventionist failed to ensure all staff adhered to infection prevention and control policies and procedures (A776). The cummulative effect of these practices resulted in a risk to the health and safety of all facility patients.

Based on observations, interviews, and policy review, the facility infection preventionist failed to ensure all staff adhered to infection prevention and control policies and procedures. This affected one patient (Patient #1) and two staff members observed (Staff D and E). The facility census was 44.

Findings include:

On 09/09/20 at approximately 8:35 AM a tour of the two wings of the facility floor was conducted with Staff B and Staff H. Upon reaching the end of the second wing, Staff D was observed in room 753, standing near the foot of the patient's bed. Staff D was not wearing a gown, gloves, or a face shield/goggles. A sign posted outside of room 753 revealed Patient #1 was in contact enteric isolation. Staff H addressed the staff member and asked why she wasn't wearing the appropriate PPE (personal protective equipment). Staff D stated she had just removed it and proceeded to exit the patient's room with a medication cart in tow. No hand washing or cleaning of the medication cart was observed at that time.

Review of Patient #1's medical record revealed he/she was in contact enteric isolation precautions due to a positive diagnosis of Clostridium difficile colitis.

Facility policy IC 4-5 (revised 10/2018) was reviewed. Per policy, "Sufficient precautions to control cross-infection in this category of isolation include proper hand hygiene, handling of linen, dressings and contaminated instruments, and the use of gowns, masks and gloves when stipulated" (p. 1).

According to the policy, "If hands are visibly soiled or if contact special enteric isolation is in place for C-Diff/Norovirus then hand washing with soap and water must be completed" (p. 2) and "All equipment that needs to be "shared" will be disinfected between patients" (p. 2).

Per policy "There will be an area no more than 3 feet into the room while maintaining a distance of at least 3 feet from the patients bed that will be considered clean. Staff may enter this area prior to donning PPE for the purpose of med administration, patient communication, charting on wallaroos, and other activities. This will be considered a safe zone. Staff should be educated that they are not to touch anything in the room without donning PPE" (p. 3).

Staff D was then observed performing medication administration to Patient #1 in room 753 between 10:25 AM and 11:05 AM. Staff D again wheeled the medication cart into the room, and to the foot of the patient's bed. During the course of administering medications, Staff E (case manager) walked into the room and approached the left side of the Patient #1's bed. Staff E was not wearing a gown, gloves, or face shield/goggles. Staff D informed Staff E the patient was in isolation, to which Staff E responded she wasn't aware. Staff E then proceeded to leave the room without washing her hands.

Once Staff D completed the medication administration, Staff D exited the room with the medication cart in tow and cleaned hands with hand sanitizer.

Upon reaching the hallway, Staff D was interviewed about the observations just made. Staff D confirmed she did not wash her hands with soap and water, and she did not clean the cart after bringing it out of the patient's room.