Failure to Isolate Residents with MDRO UTI According to Infection Control Policy
Penalty
Summary
The facility failed to ensure appropriate care and infection control practices for residents with multidrug-resistant organism (MDRO) urinary tract infections (UTIs), specifically Extended-Spectrum Beta-Lactamase (ESBL) producing E. coli. Two residents, both diagnosed with ESBL E. coli UTIs, were placed in a shared room despite facility policy and CDC guidelines recommending private room placement for residents with MDROs. Clinical records and staff interviews confirmed that both residents were on contact precautions, yet continued to share a room for an extended period, even though the facility had available private rooms. One resident, with a history of chronic respiratory failure and chronic kidney disease, tested positive for ESBL E. coli in the urine and was treated with IV antibiotics. This resident was not placed in a private room upon return from the hospital, as required by infection control policy, but instead continued to share a room with another resident. The second resident, with multiple psychiatric and neurological diagnoses, subsequently developed an ESBL E. coli UTI after sharing the room with the first resident. This resident reported being in isolation for approximately one month, which exacerbated existing anxiety. Facility documentation, including infection line listings and staff schedules, confirmed that the two residents shared a room during the period of infection and that staffing levels were sometimes below the facility's stated minimum. The Infection Preventionist and DON acknowledged that the resident with the initial ESBL infection should have been placed in a private room, and that the failure to do so was not in accordance with facility policy or CDC recommendations. The deficiency was further supported by the presence of empty beds in the facility at the time, indicating that private room placement was feasible.