Failure to Implement Transmission-Based Precautions for Suspected C. diff Infection
Penalty
Summary
The facility failed to implement transmission-based precautions for a resident who had an order to rule out Clostridium difficile (C. diff) due to frequent diarrhea. The resident, who was admitted with multiple diagnoses including diabetes mellitus, paranoid schizophrenia, major depressive disorder, and anxiety, experienced several episodes of diarrhea and incontinence. Despite these symptoms and an order to collect a stool sample to rule out C. diff, no sample was collected, and the resident was not placed on contact precautions as required by facility policy. Interviews with staff revealed that certified nursing assistants and licensed vocational nurses were aware of the resident's diarrhea and the order to test for C. diff, but did not implement any transmission-based precautions or use personal protective equipment (PPE) when providing care. The Infection Preventionist Nurse was not notified of the resident's symptoms or the need for precautions, and the Director of Nursing confirmed that the resident should have been placed on contact precautions and a stool sample should have been collected. Documentation showed that the resident had been incontinent of stool multiple times over several weeks, but appropriate infection control measures were not initiated. A review of the facility's policies indicated that contact precautions should be implemented for residents suspected of having infections such as C. diff, and that laboratory services should be provided in a timely manner according to physician orders. The failure to follow these policies resulted in a lack of appropriate infection control measures for the resident, potentially exposing other residents, staff, and visitors to the spread of infection.