Failure to Post Isolation Sign for Resident on Contact Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program by not posting an isolation sign near the room of a resident who was under contact precautions for a multidrug-resistant E. coli urinary tract infection. The resident's care plan and physician's orders specified the need for contact isolation and the posting of a precaution sign, in accordance with facility policy. However, during observation, although an isolation caddy with PPE was present on the door, there was no sign indicating the type of precautions or required PPE for entry. Interviews with facility staff, including an LVN, the Infection Preventionist Assistant, and the Director of Nursing, confirmed that an isolation sign should have been posted to alert staff and visitors of the necessary precautions. The facility's own policy also required such signage to inform staff of the type of precaution required. The absence of the sign was acknowledged by staff as a failure to follow protocol, which could have led to improper use of PPE and increased risk of infection transmission.