F0880

E

Failure to Implement Droplet Isolation for Resident With Pneumonia

Clinton, Illinois Survey Completed on 01-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement appropriate infection prevention and control measures, specifically droplet isolation precautions, for a resident with active, symptomatic pneumonia and the resulting exposure of a roommate. One resident (R4) had a history of pneumonia treated in the hospital prior to admission and later developed congestion and an active cough while in the facility. A chest X-ray completed by a private company showed opacities in the right lung base, interpreted as possibly due to atelectasis or pneumonia, and the results were reported to the facility on 11/13/25. The facility’s Infection Control Log documented that on 11/17/25, R4 had a diagnosis of pneumonia of unknown organism and was started on antibiotic therapy, and the Medication Administration Record showed amoxicillin ordered for pneumonia for 10 days.

Despite the confirmed pneumonia diagnosis and active cough, R4’s Physician Order Sheet for the relevant period did not document any order for infection control precautions, and the care plan from admission through discharge did not document that R4 was being treated for pneumonia or that isolation precautions were initiated or implemented. The MAR documented that the antibiotic was not actually administered until the evening of 11/17/25, four days after the X-ray results were reported, and continued through the morning of 11/27/25. During this time, droplet isolation precautions were never implemented from the date the X-ray confirmed pneumonia through the end of treatment, resulting in approximately 14 days of potential exposure while R4 had an active cough and was receiving treatment for pneumonia.

Another resident (R3), who had no cognitive impairment per a recent MDS, reported that R4 was brought into their room as a new roommate while R4 was actively coughing all the time and had pneumonia, which staff knew about. R3 stated that no one wore gowns or masks, that R4 coughed constantly, and that R3, who spent a lot of time in bed, had to pull the curtain when in the room because they did not want to get sick. The facility’s infection precaution policy stated that transmission-based precautions, including droplet precautions, are to be used for residents known or suspected to be infected with microorganisms transmitted by droplets from coughing, and that isolation precautions may be instituted by nursing leadership or the infection preventionist without a physician’s order. The DON and Infection Control Preventionist acknowledged that R4 had an active cough with confirmed pneumonia, that droplet isolation should have been implemented immediately, and that R4 should not have been placed in the same room with R3, who did not have pneumonia.