Failure to Implement Transmission-Based and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Transmission-Based Precautions (TBP) and Enhanced Barrier Precautions (EBP) according to its own policy and CDC recommendations for several residents. Specifically, two residents with confirmed ESBL-producing E. coli infections in their urine were placed in the same shared room, despite facility policy and CDC guidelines indicating that such residents should be placed in private rooms to prevent the spread of multidrug-resistant organisms (MDROs). Documentation showed that one resident tested positive for ESBL E. coli after sharing a room with another resident who had the same organism, and both were kept on contact precautions in a shared room. Staff interviews confirmed that the residents were not separated, and the Infection Preventionist and DON acknowledged that a private room should have been used. Additionally, the facility did not implement EBP for three residents who met the criteria for these precautions. These residents had conditions such as open wounds and indwelling Foley catheters, which, according to facility policy and CDC guidance, require EBP regardless of confirmed MDRO status. Observations during facility tours revealed that there was no EBP signage or PPE carts outside the rooms of these residents, and staff confirmed that EBP was not in place for them. The DON and IP verified that these residents should have been under EBP but were not. The facility's own infection control policies, as well as CDC guidelines, were not followed in these cases. The policies specified the need for private rooms for residents with certain infections and the use of EBP for residents with specific medical devices or wounds. Despite having available private rooms, the facility did not adhere to these protocols, and staff schedules indicated periods of minimal staffing, which may have contributed to the lapses in infection control practices.