Failure to Implement Infection Control Precautions and Signage
Penalty
Summary
The facility failed to implement proper infection control practices in two separate instances involving residents on isolation precautions. In the first instance, rehabilitation staff entered a room marked with an orange contact isolation sign, indicating the need for personal protective equipment (PPE), but did not wear a gown or gloves while providing care to a resident with an active multidrug-resistant organism (MDRO) infection. The staff member also failed to perform hand hygiene upon leaving the room and re-entered the room without donning PPE or using hand sanitizer. Interviews with facility staff, including the Director of Rehab and nursing staff, confirmed that the staff member was unaware of the resident's isolation status and the requirement to use PPE, despite the presence of the isolation sign and facility policy mandating its use for residents with MDROs. In the second instance, a resident with an indwelling Foley catheter, which requires enhanced barrier precautions (EBP) due to the risk of MDRO transmission, did not have the required EBP signage posted on the door to alert staff to use PPE. Facility policy specifies that color-coded signs must be used to indicate the need for isolation precautions, and staff interviews confirmed that such signage should have been posted upon the resident's admission. The absence of the EBP sign meant that staff were not properly alerted to the need for PPE when providing care to this resident.