Failure to Implement and Communicate Proper Infection Control Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by two specific deficiencies. For one resident with diagnoses including necrotizing fasciitis, osteomyelitis, and chronic foot ulcers, there was no physician order for enhanced barrier precautions (EBP) despite the presence of wounds on both feet. The Infection Prevention Nurse (IP) confirmed that EBP should have been ordered for this resident, as per facility policy, to ensure staff are aware of the necessary protective measures during care. Additionally, another resident with a history of cerebral infarction, pressure ulcer, muscle weakness, and sepsis was observed to have both contact precautions and EBP signage posted outside their isolation room. The IP stated that only the contact precautions sign should have been displayed due to the resident's MDRO status, as having both signs could cause confusion among staff regarding the appropriate personal protective equipment (PPE) to use. These findings were confirmed through observation, interview, and record review, and were not in accordance with the facility's own policies on EBP and transmission-based precautions.