Failure to Adhere to Contact Isolation Protocols for C. difficile
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in the care of a resident with recurrent Clostridium difficile (C. difficile) infection who was placed on contact isolation. Multiple staff members, including CNAs and housekeeping staff, were observed entering the resident's room without donning the required personal protective equipment (PPE) such as gowns, gloves, and masks, despite clear signage and a PPE station outside the room. The resident's door was repeatedly left open, contrary to expectations for contact isolation, and regular, non-disposable meal trays were used for meal service. Interviews with staff and medical professionals revealed inconsistent understanding and implementation of contact isolation protocols. Some staff admitted to not wearing PPE when entering the room, and housekeeping staff reported only wearing gloves, not gowns, when cleaning the room. The facility's management and nursing leadership stated that in-services and training on infection control and C. difficile precautions had been conducted, but staff continued to fail to adhere to the required protocols. There was also confusion regarding the use of disposable meal service items for residents on contact isolation, and the facility lacked a current policy specifically addressing contact isolation procedures. The resident involved had a history of recurrent C. difficile infections, was cognitively intact, required moderate assistance with activities of daily living, and was receiving antibiotics at the time of the deficiency. The care plan for the resident did not address contact isolation for C. difficile, and the facility's infection tracking log showed multiple cases of C. difficile in recent months. The lack of adherence to established infection control practices was observed on several occasions and confirmed through staff interviews and record review.