Failure to Implement Transmission-Based Precautions for MDRO
Penalty
Summary
The facility failed to implement transmission-based precautions for a resident who was readmitted from the hospital with a urinary tract infection (UTI) caused by an extended-spectrum beta-lactamases (ESBL) E-Coli, a multiple drug-resistant organism (MDRO). Despite the laboratory report indicating the presence of this MDRO, the facility did not initiate contact or enhanced barrier precautions as required by their policies. The resident's care plan did not include these precautions, and there was no evidence of isolation measures being implemented upon the resident's readmission or after the final laboratory report. Observations and interviews revealed that the resident was incontinent of bowel and bladder and dependent on staff for care, which included the use of incontinence briefs. However, staff did not use isolation gowns or post signs indicating the need for enhanced barrier or contact precautions. The Director of Nursing confirmed the lack of evidence for implementing these precautions, and a nurse aide confirmed the resident's incontinence and dependency on staff for care without using the necessary precautions.
Plan Of Correction
1. Resident 103 has no current active infection, contact precautions not needed. Resident 103 does not have targeted MDRO and elimination is contained and covered as described by QSO-24-08-NH, so no enhanced barrier precautions are needed. Policy "enhanced barrier precautions" to be updated to make sure reflect proper QSO guidance on enhanced barrier precautions. 2. There are no other residents to protect in a similar situation. 3. DON/Designee will educate Infection Control Preventionist (IP) on 483.80(a)(1)(2)(4)(e)(f) and QSO-24-08-NH. 4. DON/Designee will do an audit weekly x4 and monthly x3 to assure that residents are on the appropriate precautions. Results of the inspections will be submitted to the QAPI team. 5. Date of compliance 1/30/25.