Failure to Follow Infection Control Practices for Contact Isolation
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices for a resident on contact isolation due to a Clostridium difficile (C. diff) infection. The resident, who was alert but confused, was observed eating independently with food soiling her chest, lap, pillow, and cellphone. Her hands were visibly dirty, with long, unclean fingernails and rashes present on her neck, chest, and forearms. Staff were called to assist, and while one LPN removed food particles and cleaned the resident and her belongings, she used hand sanitizer instead of washing hands with soap and water after contact, despite facility policy and CDC guidelines specifying that handwashing is required after C. diff exposure. During incontinence care, a CNA failed to follow proper glove and hand hygiene protocols. The CNA disposed of a soiled brief in a regular trash can, did not use an isolation trash bin or bag for soiled linens, and placed a soiled towel on the bedside stand. The CNA applied a clean brief without removing gloves or performing hand hygiene between tasks, and when prompted, changed gloves without hand hygiene. These actions were inconsistent with both facility policy and standard infection control practices for contact isolation. Additionally, a visitor entered the resident's room without being provided or instructed to wear appropriate PPE, such as gown and gloves, and reported not being educated about isolation precautions during previous visits. The facility did not have a policy available for contact isolation setup and used regular trash cans and unit hampers for disposal of soiled items from isolation rooms, contrary to best practices. These failures were confirmed through interviews with staff, including the DON and Infection Preventionist, who acknowledged the lack of proper isolation supplies and visitor education.