Failure to Follow Infection Control Practices and Physician Orders
Penalty
Summary
The facility failed to follow infection prevention and control practices in several instances. For one resident with a physician order for contact isolation due to MRSA, the required contact isolation signage was not posted on the resident’s door. Instead, signage for Enhanced Barrier Precautions (EBP) was displayed, and staff did not update the signage even after reviewing the physician’s order. The Assistant Director of Nursing decided to maintain EBP signage, citing a perceived low risk of transmission due to antibiotic treatment, without consulting the physician for clarification. Facility policy required that appropriate transmission-based precaution signage be posted when such precautions are ordered. Another resident was placed on droplet isolation for COVID-19, as indicated by signage on the room door, but there was no corresponding physician order for droplet isolation in the medical record. Additionally, during wound care for a third resident, a CNA was observed reusing a soiled rag to clean the skin around a wound, contaminating the soapy water and the wound area, until corrected by an RN. These actions demonstrate lapses in following established infection control protocols and physician orders.