Failure to Implement Contact Precautions and Proper Hand Hygiene for Suspected C. diff Infection
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures for a resident with a history of Clostridium difficile (C. diff) who was experiencing new onset of diarrhea and was being tested for possible recurrent C. diff infection. Despite physician orders to rule out recurrent C. diff and the resident's report of loose stools, the resident was not placed on contact precautions, and there was no isolation signage or personal protective equipment (PPE) available at the room. Multiple observations over several days showed that staff, including a CNA and an LPN, entered and exited the resident's room using only hand sanitizer, without donning appropriate PPE or following hand hygiene protocols specific to C. diff, such as washing hands with soap and water. Interviews with staff revealed a lack of awareness regarding the resident's C. diff status and the required precautions. The CNA stated they were unaware of the need for contact precautions and relied on signage to identify such cases, while the RN acknowledged that the resident should have been placed on isolation when the order was received. The Director of Nursing also confirmed that precautions should have been implemented immediately. Review of the facility's policy indicated that residents with suspected or confirmed C. diff should be placed on contact precautions and that hand washing with soap and water is required, but these procedures were not followed.