Failure to Implement Transmission-Based Precautions and Infection Surveillance for Suspected C. diff
Penalty
Summary
The facility failed to implement appropriate transmission-based precautions and infection surveillance for a resident who had an active order to collect a stool sample for Clostridioides difficile (C. diff). The resident had a medical history including end stage renal disease, unspecified diarrhea, and gastritis, and was under a physician's order to collect and send a stool sample for C. diff testing with each loose stool. Documentation showed that the resident had a loose stool, prompting the order, but there was no evidence in the progress notes that the resident was placed on contact precautions or that the infection preventionist was notified. The infection surveillance line list did not include the resident, and staff interviews confirmed that the infection preventionist was unaware of the resident's symptoms and pending test. Observations revealed that the resident's room displayed an Enhanced Barrier Precautions (EBP) sign, but not a contact precautions sign as required for suspected C. diff cases. Staff interviews indicated a lack of clarity and adherence to the facility's policies regarding when to implement contact precautions and notify the infection preventionist. The facility's policies directed the infection preventionist to monitor and update infection surveillance and to implement isolation precautions as needed, but these steps were not followed in this case. No specific policy on transmission-based precautions was provided during the review.