Failure to Implement MDRO Infection Precautions for Recurrent Pseudomonas UTI
Penalty
Summary
The deficiency involves the facility’s failure to initiate and maintain appropriate infection prevention precautions for a resident with repeated UTIs caused by multidrug-resistant Pseudomonas aeruginosa. During an unannounced visit, surveyors observed that the resident, who reported being on antibiotics for a UTI and feeling better, had no signage outside the room indicating any infection prevention precautions. The Infection Prevention Nurse (IPN) explained that the facility’s process was to monitor residents on antibiotics during weekday clinical review meetings and that when a urine culture and sensitivity (C&S) showed an MDRO such as Pseudomonas, infection control interventions such as Enhanced Barrier Precautions (EBP) or Contact Isolation Precautions (CIP) should be initiated, with corresponding signage and PPE requirements posted outside the resident’s room. Record review for the cognitively intact resident showed a series of UTIs and positive C&S results for MDRO Pseudomonas. Progress notes documented that on one date in October, the resident complained of painful urination, a C&S was ordered, and antibiotics were started for a UTI. The C&S result reported on a later October date confirmed MDRO Pseudomonas, and the physician changed the antibiotic to one susceptible to the organism. However, there was no documentation that physician orders were obtained or implemented for CIP at that time, despite the IPN’s statement that CIP should have been initiated for this symptomatic MDRO UTI. The DON later confirmed that on that October date, the resident was diagnosed with a symptomatic UTI caused by Pseudomonas and that CIP was not implemented and no physician order was obtained. Further review showed that in early November the resident was transferred to an acute hospital for evaluation of recurrent UTI, where a urine C&S again showed Pseudomonas. The resident was readmitted to the facility with new antibiotic orders for UTI, but there was no documented evidence that EBP or CIP were initiated upon readmission, despite the hospital C&S indicating MDRO Pseudomonas. The IPN stated that EBP should have been started when the resident was readmitted, and the DON stated that an EBP should have been initiated upon admission for the asymptomatic MDRO UTI but was not, and that if a physician’s order is not received, it cannot be verified that precautions were initiated. Facility policies on Enhanced Barrier Precautions and Transmission-Based (Isolation) Precautions identified multidrug-resistant Pseudomonas aeruginosa as an important MDRO and required EBP for the duration of the resident’s stay and transmission-based precautions for residents known or suspected to be infected or colonized with such organisms, but these were not implemented for this resident as required.
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