Failure to Follow C. diff Infection Control Cohorting Guidelines
Penalty
Summary
The facility failed to implement its infection prevention and control program guidelines for two residents, specifically regarding the management of Clostridium difficile (C. diff) cases. One resident, who had been on contact precautions for C. diff since mid-April, was observed in a room with personal protective equipment and biohazard containers at the door, indicating awareness of the infection control requirements. However, this resident reported having had four different roommates since admission, with the most recent roommate present about a week prior to the surveyor's observation. Facility policy requires residents with C. diff to be placed in private rooms or cohorted only with other C. diff-positive residents, and to use gloves, gowns, and disposable equipment for all contact. Despite these guidelines, another resident was admitted and placed in the same room as the C. diff-positive resident, as confirmed by a grievance form and medical records. Interviews with the infection preventionist (IP) and the director of nursing (DON) revealed that the facility's practice was not to cohort C. diff-positive residents with those who were negative, and that the placement of a negative resident with a positive one was not in line with policy. The DON acknowledged that only another C. diff-positive resident should have been placed in the same room, confirming a lapse in adherence to infection control protocols.