F0880

D

Failure to Implement and Maintain Appropriate Transmission-Based Precautions for High-Risk Resident

Cortland, Ohio Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement and maintain appropriate transmission-based precautions for a resident with a history of ESBL in the urine and multiple high-risk conditions. The resident was admitted with diagnoses including dementia, saddle pulmonary embolus with acute cor pulmonale, urinary tract infection, and ESBL resistance. Physician orders dated 12/25/25 placed the resident on Contact Precautions/Isolation related to ESBL, with orders active through 01/29/26. However, the resident’s care plan from 12/25/25 through 01/28/26 did not include any care plan problem or interventions related to Contact Precautions or Enhanced Barrier Precautions (EBP), despite the active orders and the resident’s high-risk status, including chronic wounds, a PEG feeding tube, incontinence of bowel and bladder, and dependence on staff for ADLs.

The resident’s urine culture collected on 01/08/26 and reported on 01/11/26 showed less than 10,000 CFU/mL of two groups of gram-negative rods with no work-up, and progress notes documented that the finalized results were faxed to the infectious disease physician and primary care physician. The medical record from 01/11/26 through 01/29/26 did not show any physician orders changing the resident from Contact Precautions to EBP, even though staff later reported that the resident had been changed to EBP after completion of antibiotics near the end of December. On 01/29/26, a physician order was entered for EBP every shift, but there was still a Contact Precaution sign on the resident’s door. Interviews with nursing staff revealed confusion and inconsistency: an LPN and an RN stated the resident was on EBP and that staff wore appropriate PPE, while another RN stated the resident had been on Contact Precautions at the hospital and on admission but was now on EBP. Review of orders confirmed there had been no prior order to discontinue Contact Precautions and initiate EBP until 01/29/26.

Direct observations and video footage further demonstrated failures in implementing ordered precautions. Camera footage from 01/26/26 showed an LPN administering medications via the resident’s PEG tube without wearing an isolation gown. On 01/29/26, observation of the resident’s room showed a Contact Precaution sign on the door and two clean, empty PPE bins that had just been brought in that morning, with no PPE inside. The resident’s daughter reported that staff did not wear gowns and did not always wear gloves when providing care, and that gowns were first used the day before. She also provided video showing a nurse providing care without an isolation gown. The maintenance and housekeeping supervisor stated he had not supplied PPE bins to the room for at least one to two weeks and suggested housekeeping may have believed the resident was no longer on transmission-based precautions, as they rely on nursing staff to inform them. The DON confirmed there was no evidence in the care plan from 12/25/25 through 01/28/26 of any care plan for Contact Precautions or EBP, and that an EBP intervention was only initiated on 01/29/26. Facility policy on EBP required appropriate signage, PPE use (gown and gloves) for high-contact care activities, and visitor education, which were not consistently implemented for this resident.

The facility’s Enhanced Barrier Precaution policy, revised 05/19/25, specified that EBP are intended to prevent transmission of MDROs via contaminated hands and clothing of healthcare workers during high-contact activities, and that high-risk residents include those with chronic wounds and indwelling devices such as PEG tubes. The policy required staff to don gown and gloves for high-contact care activities such as dressing, bathing, transferring, hygiene, changing linens and briefs, toileting assistance, device care, and wound care, and to remove PPE before exiting the room or care area. It also required signage indicating the type of precautions and instructions for visitors to stop at the nurse’s station before entering, along with visitor education on PPE use. The documented observations, interviews, and record review showed that these policy requirements were not consistently followed for this resident, resulting in the cited infection control deficiency.

The DON reported she was filling in for the Infection Preventionist, who was newly hired and had not yet assumed the role, and that she herself was newly hired and still learning infection prevention. An RN responsible for wound care and MDS stated she discovered on 01/29/26 that the resident had not been changed from Contact to EBP despite the negative ESBL result and then wrote the EBP order that day. Staff accounts conflicted regarding when the resident’s precautions had changed, and the lack of corresponding orders, care plan updates, consistent signage, PPE availability, and observed PPE use during care all contributed to the failure to ensure appropriate transmission-based precautions for this resident.

This deficiency was investigated under Master Complaint Number 2728869 and was based on observation, interview, record review, review of camera video footage, and facility policy review, demonstrating that the facility failed to ensure the resident had appropriate transmission-based precautions implemented as ordered and as required by its own EBP policy.