Failure to Follow Contact Isolation Precautions During Meal Tray Delivery
Penalty
Summary
The deficiency involves a failure to follow contact isolation precautions for a resident with an ESBL-producing E. coli hip wound infection. The resident was admitted with diagnoses including prosthesis, subsequent encounter, aftercare following joint replacement surgery, and systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction. A physician order dated February 11, 2026, required contact isolation precautions every shift related to the ESBL E. coli hip wound infection, and the care plan initiated on February 12, 2026, identified the resident as receiving IV medications for this infection with an intervention for use of contact isolation. The admission MDS documented an active diagnosis of infection/inflammatory reaction due to an internal hip prosthesis, subsequent encounter. During a lunch tray pass observation on February 17, 2026, a CNA entered the resident’s contact precaution room without performing hand hygiene or donning PPE, despite PPE and contact precaution signage being present at the room entrance. The CNA took the lunch tray from the cart, entered the room, and placed it on the bedside table, leaning in such a way that his clothing came into contact with the resident’s bed linens, then exited the room and proceeded to reach for another tray. When questioned, the CNA acknowledged that PPE should have been used, stated he was confused because he usually worked on another hall, and confirmed he had received infection control training and understood that not donning PPE could transfer germs to other residents. Other staff interviews, including with another CNA, the Infection Preventionist, and the DON, confirmed that staff are informed of residents on precautions via report and door signage and are expected to perform hand hygiene, don PPE before entering, and remove PPE and perform hand hygiene upon exiting rooms under contact precautions, consistent with the facility’s written Contact Precautions policy.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.