F0880

F

Failure to Implement Appropriate Hand Hygiene and Contact Precautions During GI Outbreak and Suspected C. diff

Culver, Indiana Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

Surveyors identified a failure to maintain appropriate infection prevention and control practices for a resident in isolation for suspected Clostridioides difficile (C. diff) and for multiple residents placed in Contact Isolation during a gastrointestinal (GI) outbreak. At the facility entrance, signage only advised ill visitors not to enter and did not address specific transmission-based precautions. The Executive Director reported that the facility believed a GI virus, thought to be norovirus, was causing nausea, vomiting, and diarrhea among residents and staff. Symptomatic residents were placed in isolation and ate meals in their rooms, and symptomatic staff were told to stay home. However, the facility had not formally tested residents or staff to confirm norovirus.

The Infection Preventionist (IP) nurse stated that residents with GI symptoms were placed in Contact Isolation and that staff were required to wear gowns, gloves, and masks only when providing direct resident care. During observation of a room where a resident was in isolation for a possible C. diff infection, the posted Contact Precautions sign instructed staff to clean hands before entering and when leaving the room and to don gloves and gowns before entry and discard them before exit, but it did not specify that soap and water were required for hand hygiene. The nurse assigned to that resident confirmed the isolation was due to possible C. diff. The CNA caring for the resident reported that she wore mask, gown, and gloves only when providing resident care, but not when answering call lights or handing the resident items such as the call light or television remote, and that she used alcohol-based hand sanitizer rather than soap and water before entering and after exiting the room.

The IP nurse confirmed that the room was under Contact Isolation and stated that hand sanitizer was an acceptable hand hygiene method for a resident with potential C. diff, and that she was unaware that different types of Contact Isolation existed or that soap and water were specifically required for C. diff-related hand hygiene. She also acknowledged that no C. diff-specific hand hygiene education had been provided to staff after the resident was placed in isolation. The DON later stated that the IP nurse was incorrect and that the facility’s preferred method was soap and water for all hand hygiene unless unavailable, and that all staff had been trained accordingly, but she could not provide documentation of audits or training prior to survey exit. The DON also stated that all care was considered direct care and that staff should have worn gowns, gloves, and masks any time they entered an isolation room, including when handing a resident a remote, and further indicated she had not been informed in infection control meetings that soap and water was the only acceptable hand hygiene for certain Contact Isolation situations such as potential C. diff.

During continuous observation, multiple rooms were identified as being in Contact Isolation for GI symptoms, with isolation signs posted that lacked any specific instruction to use soap and water only for hand hygiene upon entering and exiting. The IP nurse reported that all residents with current or recent nausea, vomiting, or diarrhea had been placed in Contact Isolation and that Contact Isolation required gloves, mask, and gown while providing resident care, but she again stated that hand sanitizer was acceptable for hand hygiene in these rooms and that staff were not required to wear gowns or gloves when answering call lights or performing non-direct care tasks such as handing a remote or refilling water. She stated that at the start of the GI outbreak she verbally instructed staff about masks, gowns, and gloves but did not instruct them to use soap and water for hand hygiene because she did not know it was required, and she did not document this education or obtain staff signatures.

Review of the facility’s infection map showed that numerous rooms had been placed on Contact Isolation over several days for residents with nausea, vomiting, and/or diarrhea. A review of the call-off list showed several staff from different departments, including CNAs, nurses, cooks, and housekeeping, had called off work with GI symptoms during the same period. The facility’s Infection Control Surveillance Program policy required education on hand hygiene, standard precautions, and isolation protocols at orientation, annually, and in response to infection control/quality improvement data. The facility’s Hand Hygiene policy stated that employees would follow CDC standards and that hand washing with soap and water was required during care of residents with suspected or confirmed C. diff, with alcohol-based hand sanitizer preferred in most other clinical situations. CDC guidance cited in the report specified that during norovirus outbreaks, soap and water should be used for hand hygiene after caring for suspected or confirmed cases, that hand sanitizer alone does not work well against norovirus, and that washing hands with soap and water is the best way to prevent spread of C. diff.