Failure to Implement Infection Control Precautions for Residents Exposed to Impetigo
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices for three residents who shared a room, following a physician's diagnosis of impetigo in one of the residents. After the diagnosis, the resident with impetigo was not immediately placed on contact isolation, despite a physician order for transfer to a hospital and a text message from the Infection Preventionist indicating the need for isolation. The resident remained in the shared room for approximately eight hours after the need for isolation was identified, without any isolation signage or precautions in place. The two roommates who were exposed to the resident with impetigo were also not placed on isolation or enhanced barrier precautions during or after the exposure. Staff interviews revealed that neither the Director of Nursing nor the assigned nurses and CNAs were aware of the need to implement isolation or enhanced barrier precautions for the exposed residents. No isolation signage was posted outside the room, and staff did not use personal protective equipment (PPE) when providing care to any of the three residents during the period of exposure. Record reviews confirmed that there were no physician orders or care plans initiated for isolation or contact precautions for the affected residents. The facility's own policies, as well as CDC guidelines, require contact precautions for suspected or confirmed cases of impetigo to prevent transmission. The Infection Preventionist and Director of Nursing acknowledged during interviews that the facility did not follow these guidelines or their own policies, and that the necessary precautions were not implemented in a timely manner.