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F0550
D

Resident Confined to Room During Contact Isolation Despite Independence

Rockford, Illinois Survey Completed on 05-14-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident with a history of type 2 diabetes, fibromyalgia, generalized anxiety, chronic pain, restless leg syndrome, major depression, and a urinary tract infection (UTI) was placed on contact isolation after a urinalysis revealed Klebsiella pneumonia (MDRO). Physician orders indicated contact precautions for E. coli in the urine. Initially, staff informed the resident that she could leave her room if she practiced hand hygiene, but this guidance was later changed, and she was required to remain in her room with the door closed for the last four to five days of her isolation period. The resident, who was independent in her care and compliant with hand hygiene, was not allowed to leave her room despite her requests and inquiries to multiple staff members, including the Assistant Administrator and previous DON. Staff consistently told her that remaining in her room was facility policy. Interviews with staff, including the Unit Manager, RN, Assistant Administrator, and previous DON, confirmed that the resident was not permitted to leave her room while on contact isolation, even though she was independent and able to follow infection control measures. The Corporate RN stated that residents on contact isolation for a UTI could leave their rooms if they performed hand hygiene and avoided contact with other residents or food. The facility's actions resulted in the resident being confined to her room against her wishes, without clear justification based on her ability to comply with infection control protocols.

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