Failure to Implement Infection Control and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to properly implement infection prevention and control measures for residents with acute gastrointestinal infections and those requiring enhanced barrier precautions. One resident began experiencing acute diarrhea and was later confirmed to have a C. difficile infection. Despite this, the resident was not immediately placed on contact precautions, and their roommate, who was at risk for infections due to multiple comorbidities, was not moved to another room until three days after the onset of symptoms and one day after the positive test result. Facility policy and CDC guidelines require immediate implementation of contact precautions and cohorting only with other residents with the same infection, but these were not followed. Additionally, a nurse failed to adhere to enhanced barrier precautions for another resident with a gastrostomy tube and colonization with a multidrug-resistant organism. The nurse entered the resident's room and performed high-contact care activities, including medication administration through the feeding tube, without wearing a gown as required by facility policy. The resident's care plan and facility policy both specified the need for gown and glove use during such activities to prevent the transmission of infectious agents.