Failure to Maintain Infection Surveillance and Adhere to Contact Isolation Precautions
Penalty
Summary
The facility failed to implement proper infection control policies and procedures, specifically in the areas of infection surveillance and adherence to contact isolation precautions. Review of infection control surveillance logs revealed that the facility did not maintain surveillance records for three consecutive months. The Assistant Director of Nursing confirmed that infection tracking was not documented for these months and was unable to explain how infection trends were monitored without up-to-date logs. Facility policy required the infection prevention and control nurse to track and monitor infections and antibiotic use, but this was not consistently done as evidenced by the missing logs. Additionally, the facility did not ensure staff compliance with contact isolation precautions for a resident diagnosed with ESBL, a multi-drug resistant organism. The resident had a physician's order for contact precautions, and signage on the door instructed staff and visitors to wear gowns and gloves. During observation, an LPN performed hand hygiene and donned gloves before entering the resident's room to provide care but failed to wear a gown as required. The LPN acknowledged the omission, and facility policy confirmed that both gown and gloves were necessary for contact isolation.