Failure to Implement Timely Infection Control Measures for Suspected C-diff
Penalty
Summary
The facility failed to implement an effective infection prevention and control program for the surveillance and prevention of gastrointestinal disease transmission in one resident. Despite facility policy requiring nursing staff to initiate transmission-based precautions for suspected infectious diarrhea and to notify the attending physician and Infection Preventionist, these steps were not followed when a resident exhibited three episodes of watery stool with significant mucous and foul odor. Certified Nursing Assistants observed changes in the resident's stool consistent with previous C-diff infection but were instructed not to use transmission-based precautions, and no signage or personal protective equipment was present outside the resident's room. The resident, who had a history of chronic diarrhea and prior C-diff colonization, was not placed on precautions despite acute changes in stool characteristics. Interviews with staff revealed confusion and lack of communication regarding the need for precautions, with CNAs expressing uncertainty about protocol and reporting that they were not informed of the resident's change in condition. The Infection Preventionist and Market Clinical Advisor were unaware of the resident's acute symptoms until informed by surveyors, and the facility provider confirmed that the changes in stool warranted precautions and further testing, but they had not been notified. The failure to recognize and respond to the resident's symptoms in a timely manner resulted in a delay in implementing appropriate infection control measures.