Failure to Follow Transmission-Based Isolation Policy for ESBL Infection
Penalty
Summary
The facility failed to follow its transmission-based isolation policy for two residents when one resident was found to have Extended-Spectrum Beta-Lactamases (ESBL) in the urine. Despite a physician order for contact isolation, census records show that the resident's roommate was not relocated during the period of isolation, even though open beds were available. The facility's policy requires that either the infected resident or their roommate be moved to prevent transmission, but this was not done according to the census documentation. Additionally, the order for contact isolation was not discontinued after the completion of treatment, contrary to facility policy, which states that isolation should end once treatment is completed. The residents involved included one with a history of dysuria, weakness, hernia, major depressive disorder, and ulcerative colitis, who required maximal assistance with toileting and was frequently incontinent. The roommate had diagnoses including Alzheimer's disease, dementia, bipolar disorder, and schizoaffective disorder, with moderately impaired cognition. The Infection Prevention RN confirmed that the roommate should have been moved and that the isolation order should have been discontinued after treatment, but these actions were not reflected in the records.