Failure to Follow Contact Precautions and Document Infection Surveillance
Penalty
Summary
The deficiency involves the facility’s failure to implement proper infection prevention and control practices for a resident on contact precautions and to document community infection control surveillance mapping. A resident admitted with diagnoses including C. difficile enterocolitis, urinary tract infection, and psychoactive substance abuse had a comprehensive care plan and physician order requiring single-room contact precautions, including use of gowns and gloves for high-contact care, gowns and masks when changing contaminated linens, and conducting all care, therapies, and activities in the room. Signage outside the resident’s room indicated contact precautions and the need for PPE, and an isolation cart with gowns, gloves, masks, and sanitizing wipes was present. Surveyors observed a CNA exiting this contact isolation room after delivering a meal tray without performing hand hygiene. After exiting, the CNA handled another meal tray on the food cart and pushed it back into the cart, and there was no evidence that this tray was discarded while staff continued to pass meal trays from the same cart. In interviews, the CNA acknowledged exiting the room without hand hygiene and stated that staff are required to don gowns and gloves when entering, doff them before exiting, use disposable meal trays, perform hand hygiene, and disinfect reusable items for residents on contact precautions. An LPN and the Administrator, along with the Infection Preventionist, confirmed that proper PPE use and adherence to contact precautions are required, including when delivering meal trays. The facility’s IPCP policy required hand hygiene per facility procedures and use of PPE according to policy, but these practices were not followed in this instance, and the facility also failed to document community infection control surveillance mapping as part of its infection prevention and control program.
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