Failure to Implement Infection Control Measures for Resident on Precautions
Penalty
Summary
The facility failed to implement proper infection prevention and control measures for a resident with multiple health conditions, including pneumonia, diabetes mellitus, and dementia. During an observation, a visitor was seen assisting the resident with repositioning without wearing any personal protective equipment (PPE) such as a mask, gown, or gloves, despite the resident being on Enhanced Barrier Precautions (EBP). The EBP signage was not placed in a visible location, and neither staff nor signage provided adequate education or instruction to the visitor regarding the need for PPE. Staff members also acknowledged that the signage was not easily visible and that they had not educated the visitor about PPE requirements. Additionally, the facility did not place the resident on contact isolation after the resident experienced multiple episodes of diarrhea and while awaiting lab results for possible Clostridium difficile infection. There was no isolation signage or isolation cart present, and staff did not implement contact precautions as required by facility policy. A nurse performed hand hygiene with sanitizer instead of soap and water after providing care, contrary to policy for suspected C. diff cases. The care plan for the resident addressed diarrhea with medication and fluid intake but did not include interventions for contact isolation precautions. Interviews with staff, including the Infection Preventionist Nurse and Director of Nursing, confirmed that the required infection control measures were not followed. Staff acknowledged that both staff and visitors should have been educated and required to use PPE, and that the resident should have been placed on contact isolation while awaiting lab results. Facility policies reviewed indicated clear procedures for EBP and contact precautions, which were not implemented in this case.