Delayed Implementation of Infection Control Precautions
Penalty
Summary
The facility failed to implement effective infection prevention and control practices, specifically in the timely initiation of Enhanced Barrier Precautions (EBP) and Transmission-Based Precautions (TBP) for residents diagnosed with multidrug-resistant organisms (MDROs). The report highlights that four residents, who should have been placed on EBP and TBP, experienced delays in the initiation of these precautions. For instance, Resident #80 had a delay of four days in starting TBP after being diagnosed with extended-spectrum beta-lactamase (ESBL) bacteremia. Similarly, Resident #31 experienced a one-day delay in TBP initiation after an ESBL diagnosis. The report further details that Resident #6 had a two-day delay in starting EBP after being diagnosed with ESBL. Additionally, Resident #129, who was diagnosed with ESBL, did not have the required contact precautions signage posted on their door, indicating a lapse in the facility's adherence to its own infection control policies. These lapses were identified during a survey, and the facility's Infection Preventionist acknowledged the delays in implementing the necessary precautions. The facility's failure to provide appropriate education or ensure competency among staff regarding infection control practices was also noted. The Infection Preventionist admitted to not conducting documented competency assessments or in-service training related to infection control, which contributed to the deficiencies observed. The report indicates that the facility had been experiencing an increase in facility-acquired infections, yet there was a lack of documented evidence of corrective actions or staff education to address these issues.
Plan Of Correction
Appropriate control and/or isolation precautions were initiated for residents #129, #80, #31, and #6 on Residents on were audited on to ensure that the proper precautions were in place. If precautions were to be found missing they were initiated immediately. Licensed nurses will be educated on transmission based precautions and enhanced barrier precautions by the Director of Education/Preventionist/designee. Orders and precautions will be reviewed by a member of the clinical team daily to ensure that precautions are implemented timely. Orders and precaution signs will be audited weekly x4 weeks then monthly x12 months. The results of these audits will be brought to the QAPI committee monthly for review.