Failure to Implement Physician-Ordered Contact Isolation Precautions
Penalty
Summary
The facility failed to follow a physician's order for contact isolation precautions for a resident diagnosed with a urinary tract infection (UTI) caused by Extended-Spectrum Beta-Lactamases (ESBL), a bacteria resistant to many antibiotics. According to the facility's infection control policy, residents with infections are to be placed under appropriate isolation precautions. The resident in question had a physician's order specifically for contact isolation due to the ESBL UTI. Despite this order, observations on multiple occasions revealed that the signage on the resident's door indicated enhanced barrier precautions rather than contact isolation. Interviews with the Assistant Director of Nurses (ADON) and the Director of Nurses confirmed that the resident was supposed to be in contact isolation, and both acknowledged that the room signage was incorrect at the time of the observations. The discrepancy between the physician's order and the implemented precautions constituted a failure to follow prescribed infection control measures.