F0880

E

Failure to Follow Contact Isolation and Equipment Disinfection for ESBL-Positive Resident

Scottsdale, Arizona Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

A deficiency occurred when staff failed to follow the facility’s infection prevention and control program and contact isolation policies for a resident with an active ESBL E. coli urinary tract infection. The resident was admitted from a short-term general hospital for IV infusions with contact isolation and had diagnoses including end stage renal disease and type 2 diabetes mellitus. Physician orders documented contact isolation due to ESBL for a defined period, and the care plan identified an active ESBL infection with interventions such as contact/droplet isolation precautions, staff and resident education on infection containment, use of disposable or dedicated equipment, appropriate cleaning and disinfection of non-disposable equipment, and provision of independent or 1:1 activities.

On the day of the survey observation, a CNA entered the resident’s room, which had a contact isolation sign posted on the right side of the doorway and an isolation cart with PPE outside the room. The CNA pushed a vitals cart into the room without performing hand hygiene and without donning a gown or gloves, despite the posted contact isolation precautions. The CNA proceeded to take the resident’s vital signs using the blood pressure cuff on the resident’s ankle while the resident was in bed, then closed the door and later exited the room without sanitizing the vitals cart. The CNA then pushed the unsanitized vitals cart down the hallway to the therapy gym and left it there.

In a subsequent interview, the CNA stated that staff identify isolation rooms by signs on the door indicating the type of precautions and required PPE, and that for contact precautions, staff are required to wear a gown and gloves. The CNA also stated that equipment brought into an isolation room and then used for other residents should be sanitized with sanitizing wipes, but she did not sanitize the vitals cart because she did not know where wipes were located and none were present in the isolation cart. She reported she had not received verbal report at shift change about which rooms were on isolation, did not initially realize the room was an isolation room because the sign was posted to the side of the door rather than in the center, and was unfamiliar with disposable or single-use blood pressure cuffs or stethoscopes. When the room was re-observed with the CNA, she acknowledged the contact isolation sign. Other nursing staff, including an RN/unit manager, an LPN, and the DON, described expectations consistent with facility policy: observing isolation signage, donning required PPE before entry, performing hand hygiene before leaving the room, dedicating or disinfecting equipment with sanitizing wipes before reuse, and maintaining PPE and supplies in or near the room, and they stated that failure to follow these practices could result in spread of infection.

Review of facility policies on "Managing Infections: Isolation - Categories of Transmission-Based Precautions" and "Managing Infections: Isolation - Initiating Transmission-Based Precautions" showed that transmission-based precautions are to be initiated for residents with transmissible infections or laboratory-confirmed infections at risk of transmission. Policies require appropriate signage on the room entrance door and chart, use of standard precautions at all times, and additional contact precautions for residents known or suspected to be infected with organisms transmitted by direct or indirect contact. The policies specify that non-critical resident-care equipment such as stethoscopes, sphygmomanometers, and thermometers should be dedicated to a single resident when possible, or cleaned and disinfected before use with another resident if reuse is necessary. They also require gloves and disposable gowns upon entering the room, removal of PPE and performance of hand hygiene before leaving the room, and ensuring that PPE and necessary supplies, including appropriate waste and linen containers, are maintained in or near the resident’s room. The observed staff actions did not align with these written requirements.