Failure to Implement and Enforce Infection Control Precautions
Penalty
Summary
The facility failed to ensure proper infection control protocols and practices for the implementation of Enhanced Barrier Precautions (EBP) and Transmission-Based Precautions (TBP) for two residents. For one resident with a history of sepsis, urinary tract infection (UTI) with ESBL resistance, and ongoing antibiotic treatment, the facility did not implement the correct level of precautions upon admission. Despite hospital discharge orders specifying contact isolation for ESBL-positive urine, the resident was placed on EBP instead of contact precautions. This error was not identified until after staff interviews and review of the resident's medical record, during which it was acknowledged by both the interim infection preventionist and the RN that the resident should have been on contact precautions. Additionally, after the signage was corrected, therapy staff were observed entering and exiting the resident's room without donning any PPE, contrary to the required protocols for contact precautions. For another resident with a wound, the facility failed to implement EBP as ordered. The resident had a current order for EBP due to a wound, and PPE was available outside the room, but there was no signage indicating the need for precautions. Staff were observed entering and providing care to the resident without donning or doffing PPE, and there was no evidence of used gowns in the trash, indicating non-compliance with EBP protocols. Interviews with staff revealed confusion regarding the reason for EBP and a lack of awareness of the resident's current wound status and the need for precautions. The infection preventionist reported relying on communication from the wound care nurse to discontinue EBP orders, but the resident continued to have active wound care orders and wound documentation. The facility's own infection prevention and control policies require staff to follow established protocols for standard and transmission-based precautions, including the use of PPE and appropriate signage. However, observations and interviews demonstrated that staff did not consistently follow these protocols, leading to lapses in infection control practices for residents requiring EBP or TBP. These deficiencies were identified through direct observation, record review, and staff interviews, highlighting failures in both the implementation and communication of infection control measures.