Failure to Implement and Document Required Infection Control Precautions
Penalty
Summary
The facility failed to follow established infection prevention and control practices for residents requiring Enhanced Barrier Precautions (EBP) and Contact Precautions. For one resident with a wound, there was no EBP signage or Personal Protective Equipment (PPE) available in or outside the room during multiple observations, despite the resident having an active wound infection and orders for wound care. The Infection Preventionist confirmed that EBP orders and PPE should have been in place, but follow-up observations showed continued non-compliance. Additionally, three residents with documented infections requiring Contact Precautions did not have appropriate physician orders in place. One resident with an ESBL-positive wound had a Contact Precaution sign posted but lacked a corresponding order. Two other residents with ESBL E. coli bacteremia and MRSA infections had care plans indicating the need for transmission-based precautions, but no active Contact Precaution orders were found in their records. In one case, only an EBP sign was present when Contact Precautions were required. Interviews with the Infection Preventionist confirmed that the necessary orders and precautions were not implemented as required by facility policy. The deficiencies were identified through record reviews, direct observations, and staff interviews, highlighting lapses in the execution of infection control protocols for residents with wounds and multidrug-resistant organism (MDRO) infections.