F0880

D

Failure to Implement Contact Precautions and Hand Hygiene for Resident With C. diff

Wabash, Indiana Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to consistently implement appropriate infection prevention and control measures, specifically contact precautions and hand hygiene, for a resident with an ongoing Clostridioides difficile (C. diff) infection. The resident had a history of C. diff, was admitted with C. diff and a UTI, and continued to experience loose, unformed stools and bowel incontinence over an extended period. Clinical records documented multiple positive C. diff stool tests, repeated courses of oral vancomycin, and ongoing abdominal discomfort and loose stools. Orders and care plans indicated the resident required contact precautions for C. diff and enhanced barrier precautions (EBP) during high-contact care, with specific instructions for staff to wear gowns and gloves and to perform hand hygiene with soap and water before and after care.

Surveyors observed inconsistent and incorrect use of isolation signage and precautions at the resident’s room. Initially, an EBP sign was posted under the resident’s nameplate, but later this was removed and replaced with a contact precautions sign. The Infection Preventionist and DON acknowledged confusion over which sign should have been in place, and the Infection Preventionist stated the resident probably should have remained on contact precautions the whole time due to C. diff. Documentation showed that when COVID-19 droplet precautions were discontinued, staff removed the contact precaution sign and left only the EBP sign, despite existing orders for C. diff contact precautions. Progress notes also conflicted, with some entries indicating no isolation precautions were needed while others documented that C. diff precautions and contact isolation were in place.

Direct care observations showed staff and therapy personnel did not follow required contact precautions or hand hygiene practices when interacting with the resident or her environment. A physical therapist entered the resident’s room without PPE, handled the resident’s gait belt and wheelchair with bare hands, transported the resident to and from therapy, and did not perform hand hygiene upon entering or exiting the room; the resident also did not perform hand hygiene. The therapist later stated he believed the contact precaution sign applied mainly to nursing staff and that hand hygiene was addressed by occupational therapy. A CNA similarly entered the resident’s room without PPE, handled the wheelchair with bare hands, transported the resident to the dining room, and then obtained and served coffee without washing hands, later acknowledging she should have washed her hands because the resident had a bacterial infection. Interviews with nursing staff confirmed that the resident required assistance with toileting and handwashing with soap and water due to C. diff, and that gowns and gloves were to be worn when providing personal care or touching personal items, but these practices were not consistently followed.

Additional interviews with the Infection Preventionist, DON, and a clinical support specialist revealed that contact precautions were intended for residents with transmissible infections such as C. diff and MRSA, while EBP was for residents with devices or wounds and was described as protecting the resident from staff. The Infection Preventionist stated that staff education on isolation was primarily directed to nursing staff, as other departments were not considered to provide hands-on care, even though therapy and housekeeping staff entered the resident’s room and interacted with the environment. The facility’s own policies on the Infection Prevention and Control Program and Guidelines for Contact Precautions required surveillance, monitoring of compliance, appropriate signage, and use of gloves and handwashing after contact with the resident or potentially contaminated environmental objects. Despite these policies and the resident’s documented diagnosis and orders, the facility did not ensure consistent implementation of contact precautions, correct signage, and required hand hygiene for all staff interacting with the resident and her environment.