Delay in Implementing Contact Precautions for VRE Infection
Penalty
Summary
The facility failed to ensure timely implementation of transmission-based precautions for a resident with a confirmed infection. A review of the facility's policies indicated that standard and transmission-based precautions, including contact precautions for infections such as Vancomycin Resistant Enterococcus (VRE), are to be implemented as soon as a resident is known or suspected to be infected. Resident 83 was admitted on February 21, 2025, and a urine culture collected on April 23, 2025, showed the presence of enterococcus faecium VRE. The physician documented the positive result and initiated antibiotic treatment, with an order for contact precautions placed on April 27, 2025. Despite the order, there was a delay in starting the required contact precautions for the resident. The infection preventionist confirmed during an interview that the nurse supervisor did not implement the transmission-based precautions over the weekend, resulting in a lapse in infection control practices. This delay was identified during a review of the resident's clinical record and staff interviews, and the issue was discussed with the Director of Nursing.