Failure to Follow Contact Precautions for Resident with ESBL
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as required for residents with communicable diseases. Specifically, a resident with a diagnosis of ESBL in the urine had a physician's order for contact precautions, which included the use of gowns and gloves upon entering the resident's room. Surveyor observations revealed that a nursing assistant entered the resident's room on multiple occasions without performing hand hygiene and without donning the required gown and gloves, despite clear signage on the door indicating the need for contact precautions. The nursing assistant also entered another resident's room and then reentered the room of the resident on contact precautions, again without following proper infection control procedures. Interviews with the nursing assistant revealed a lack of awareness regarding the resident's contact precautions order and a misunderstanding of when to use personal protective equipment (PPE). The assistant director of nursing and the infection preventionist confirmed that the resident was actively being treated for ESBL and that staff were expected to perform hand hygiene and wear gowns and gloves upon entering the room. The failure to adhere to established infection control protocols was directly observed and acknowledged by staff during the survey.