Failure to Ensure Correct Precaution Signage and Infection Control Practices
Penalty
Summary
The facility failed to ensure appropriate infection prevention and control practices for two residents with a history of Multi Drug Resistant Organism (MDRO) and one resident with an indwelling medical device. For both residents, the care plans indicated a history of Extended Spectrum Beta-Lactamase (ESBL) in the urine, but the care plans lacked current problems or interventions for Enhanced Barrier Precautions related to this history. Physician orders did not consistently reflect the need for special precautions, and there was no current order for Enhanced Barrier Precautions for the resident with an indwelling medical device. Observations revealed that incorrect precaution signage was posted outside the residents' shared room. Initially, a sign for droplet and contact precautions for unknown Covid-19 was displayed, which did not accurately reflect the residents' needs. Staff interviews confirmed that the sign was used due to the MDRO history, but staff did not follow the PPE requirements listed on the sign, and there was confusion about which precautions were appropriate. The sign was later changed to enteric contact precautions, which also did not match the residents' conditions. Staff were unable to clearly articulate the policy or procedure for posting precaution signs and relied on shift handoff reports for information about resident precautions. Further interviews with nursing staff and the Infection Preventionist revealed inconsistent processes for ensuring correct signage and communication to staff and visitors regarding required precautions. The Infection Preventionist was responsible for posting and auditing precaution signs but did not provide a clear rationale for the signage used. The facility was unable to provide policies for Enhanced Barrier Precautions, Contact Precautions, or Droplet Precautions when requested.