Failure to Post Isolation Signage for Resident with Shingles
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for a resident who was placed in isolation due to shingles. Although the resident was moved to isolation and had personal protective equipment (PPE) available outside her room, there was no signage posted on the door to alert visitors and staff that the resident was under isolation precautions. Multiple staff interviews confirmed that the resident was on contact precautions for shingles, but the required signage was missing. Staff members acknowledged noticing the absence of signage but did not report it, and responsibility for ensuring signage was posted was attributed to nursing administration and the infection preventionist nurse. Record reviews indicated that the resident had a history of seizures, poor coordination, aphasia, anxiety, psychosis, and schizoaffective disorder, and was cognitively severely impaired. The care plan and physician orders documented the need for isolation and antiviral treatment for shingles. Despite these documented precautions, the lack of isolation signage was observed during the survey, and staff interviews confirmed that this omission could result in visitors or staff entering the room without appropriate PPE, increasing the risk of cross-contamination.