Failure to Implement Transmission-Based Precautions for Norovirus
Penalty
Summary
The facility failed to implement appropriate transmission-based precautions for 11 out of 16 residents who were reviewed. These residents exhibited symptoms of gastrointestinal illness, such as nausea, vomiting, and diarrhea, which were being treated as positive for Norovirus. Despite the facility's policy requiring residents with infections to be placed on transmission-based precautions, several residents did not have physician orders for Contact Precautions, and for those who did, there was a lack of signage indicating the precautions outside their rooms. Observations revealed that residents with symptoms of Norovirus were not consistently placed on Contact Precautions as required by the facility's policy and CDC guidelines. For instance, residents with symptoms starting from various dates did not have corresponding physician orders for Contact Precautions, and even when orders were present, there was no signage outside their rooms to indicate the need for such precautions. This lack of signage was confirmed during interviews with staff, who acknowledged that signs should be present to indicate isolation precautions. Interviews with the Director of Nursing (DON) and a Registered Nurse (RN) further confirmed the deficiency. The DON admitted that the facility failed to implement the necessary precautions for the affected residents, and the RN noted that isolation signs were not consistently placed on the doors of residents who were supposed to be on isolation precautions. The facility's failure to adhere to its own policies and CDC guidelines resulted in a significant lapse in infection control measures for residents with gastrointestinal symptoms.
Plan Of Correction
All residents who were experiencing diarrhea or vomiting symptoms as of 12/26/2024 were reviewed and any missing orders were added to the resident's medical record. Appropriate isolation signage was placed to the door of any resident with orders for isolation if signage was found to be missing. Setup for all residents who had an isolation setup ensured to have an order for isolation and contact isolation signs in place. Any resident who has illness or symptoms that require isolation has the potential to be affected by this alleged aberrant practice. Team members will be educated by the Director of Nursing/designee before the compliance date on the appropriate isolation protocols and setup to include physician orders for the isolation and isolation precaution signage at the resident's door while the isolation is in place. An isolation checklist will be developed to help guide the nursing team any time a resident is placed in isolation precaution. The Director of Nursing/designee will complete audits weekly for six weeks to ensure all isolation precaution protocols including physician orders and appropriate signage are in place for residents who are ordered isolation. Audits will be reviewed by the QAPI committee until such time consistent substantial compliance has been achieved as determined by the QAPI committee.