Failure to Implement and Maintain Contact Isolation Protocols
Penalty
Summary
The facility failed to follow established contact isolation protocols for two residents with infectious conditions. Specifically, the facility did not place the correct contact isolation signage on the resident's room door, did not ensure that a resident on contact isolation was placed in a private room, and did not properly contain a resident's breathing mask after use. One resident with a history of MRSA infection, pressure-induced deep tissue damage, and other significant medical conditions was observed sharing a room with another resident, with only enhanced barrier precaution signage posted. The resident's breathing mask was left open to air at the bedside, contrary to infection control protocols. The resident was also observed moving freely throughout the facility and attending group activities. Facility records indicated that the resident was still on contact isolation for MRSA and C. difficile, with care plans specifying that the resident should remain in their room and that staff should adhere to contact isolation protocols. However, there was no documentation from a physician or infection preventionist discontinuing the contact isolation, despite staff statements that the hospital had discontinued it. The facility was unable to provide documentation supporting the discontinuation of isolation, and the Director of Nursing confirmed that the resident should have been in a private room with appropriate signage and that the breathing mask should have been contained after use.