Failure to Follow Contact Isolation Precautions and Develop Care Plan for Infection Control
Penalty
Summary
Staff failed to follow transmission-based precautions for a resident who was placed on contact isolation due to a Clostridium difficile (C. diff) infection. Observations revealed that a Certified Nurse Assistant (CNA) donned personal protective equipment (PPE) inside the resident's room, rather than before entering, and a Licensed Vocational Nurse (LVN) was present in the room without any PPE. Both staff members were unsure of the reason for the contact isolation, despite signage indicating the need for precautions. Facility policy requires PPE to be donned prior to room entry to prevent contamination and the spread of infection. Additionally, there was no care plan developed or implemented to address the resident's contact isolation precautions. The Director of Nursing (DON) confirmed that a comprehensive, resident-centered care plan should have been created by the interdisciplinary team to outline specific interventions and staff responsibilities for infection control. The lack of a care plan and failure to follow PPE protocols were identified through observation, interviews, and record review, and were not in accordance with the facility's own policies and procedures.