HospitalInspections.org

Based on a tour of the facility, review of facility documentation and policies and procedures and medical records (MR), and staff interviews (EMP), it was determined that the facility failed to followed the contact isolation precautions for one medical record reviewed (MR10).
Findings include:
Review of facility policy and procedure "Precautions For Methicillin Resistant Staphylococcus Aureus (MRSA)" reviewed August 2010, revealed "...C. Isolation Precautions for Patients with MRSA: 1. Patients with MRSA in their trach and patients without a trach who have MRSA in their sputum: Place in droplet isolation on admission Wear mask if coming within 3 feet of the patient ... Wear gown if contact with infective material is likely. ....Patients may come out of room only for therapy and diagnostic testing. The trached patient must wear a barrel and surgical mask over trach to protect those whom they come in contact. These patients should not eat meals in rec room ... Record in the EMR clinical conditions of isolation precautions... ."
Review of facility policy and procedure "Techniques And Recommendations For Isolation Precautions" reviewed April 2017, revealed "Procedure ... a. Obtain order for isolation procedures ... d. Initiate/update care plan e. Complete and document education for standard precautions or transmission based precautions as applies ... Droplet: Intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. ... Mask: wear regular surgical mask when entering the room or when ever you come within 3 feet of the patient. 4. Transport: Patient may come out of their room, for essential purposes. Have the patient put on a regular mask during transport. Notify area receiving patient of the precautions... ."
Review of facility policy and procedure "Personal Protective Equipment" revised January 2017, revealed "....Policy (Guidelines) ... 2. All staff shall wear appropriate protective equipment whenever it is reasonably anticipated that they will be in contact with blood or body fluids from any patient. 3. Personal protective equipment shall include: gloves, gown, mask, protective eyewear/face shield... ."
1. During an interview with EMP2 on June 14, 2017, at approximately 9:55 AM, EMP2 was asked if any patients were in droplet or airborne precautions. EMP2 replied, "no."
2. During a tour of the facility on June 14, 2017, at approximately 10:30 AM EMP5 was observed entering room 301 and gloving. Also observed was a sinage on the door of room 301 which stated "Droplet/Contact Precautions".
3. During the tour EMP4 confirmed that the patient in Room 301 was in droplet precautions. EMP4 stated, "yes, [ ] was put in today." During further interview EMP4 confirmed the need to wear personal protective equitment and also confirmed that EMP5 did not use personal protective equipment, as per facility policy.


4. Further review of MR10 revealed no documentation the patient or family was educated on droplet isolation precautions or that the care plan was updated, as per facility policy.

During the review of MR10 and interview with EMP4 and EMP5 confirmed the above findings.