Failure to Enforce Contact Isolation for Resident with ESBL
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically in the case of a female resident diagnosed with ESBL (Extended-Spectrum Beta-Lactamase) in her urine. Despite physician orders for contact isolation, the resident repeatedly refused to remain in her room, declined the use of a bedside commode, and continued to ambulate throughout the facility, including attending smoking activities and visiting common areas. Staff documented multiple instances where the resident was educated on the importance of infection control and isolation, but she remained non-compliant, often removing isolation signage and disregarding staff redirection. The resident's medical history included mixed anxiety and depressed mood, heart disease with a cardiac defibrillator, hypertension, opioid dependence, and seizure disorder. She was cognitively intact according to her BIMS score but exhibited behaviors such as verbal aggression, wandering, and non-compliance with care and facility policies. Staff and the physician noted that the resident was independent with most activities of daily living, including toileting, and wore an adult brief for incontinence. However, there was no effective intervention in place to ensure she remained isolated or to monitor her hand hygiene after toileting, which was identified as a potential vector for infection transmission. Observations and interviews confirmed that the resident was frequently seen outside her room, including entering the kitchen and walking in hallways near other residents, without staff consistently present to redirect her. Staff acknowledged the resident's non-compliance and reported it to nursing, but no additional measures were implemented to enforce isolation. The facility's policy required transmission-based precautions for residents with transmissible infections, but in this case, the interventions were not effective in preventing the resident from potentially spreading ESBL to others.