Failure to Implement and Educate Staff on Reverse Isolation Precautions
Penalty
Summary
The facility failed to ensure there was a policy and procedure in place for reverse isolation, and staff were not knowledgeable about the requirements for reverse isolation as ordered by the physician for a resident who was immunocompromised. The resident, who had diagnoses including pancytopenia and immunodeficiency due to drugs, was admitted with a physician's order for reverse isolation following critically low white blood cell and platelet counts. Despite the order, staff actions were inconsistent: some staff entered the resident's room without donning personal protective equipment (PPE), and there was confusion among staff and leadership regarding what reverse isolation entailed. Observations confirmed that signage and PPE were inconsistently used, and staff interviews revealed varying interpretations of the reverse isolation order, with some staff believing PPE was no longer required and others unsure of the specific precautions needed. Further interviews with the DON, who also served as the facility's Infection Preventionist, and the Administrator confirmed that the facility did not have a policy covering reverse isolation and had not clarified the physician's order. The physician indicated that the use of PPE would depend on the facility's policy, but no such policy existed. This lack of clear policy and staff education resulted in inconsistent implementation of reverse isolation precautions for the immunocompromised resident.