Infection Prevention: When a Breakdown Becomes Immediate Jeopardy
Infection prevention and control (IPC) is one of the most important safety systems in long-term care. However, some of the most serious infection control citations occur because IPC policies and procedures fail at the point of care. When systems fail, a seemingly simple infection control breach can become much more serious when the circumstances create a significant risk of harm to our vulnerable populations.
When nonadherence causes, or is likely to cause, serious injury, harm, impairment, or death to a resident, these citations lead to immediate jeopardy. Below are some examples of citations resulting in immediate jeopardy.
Failure to Implement Transmission-Based Precautions
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- A resident developed symptoms of a Norovirus.
- Staff continued providing care without appropriate precautions while awaiting test results.
- During this time, staff continue to care for other residents throughout the facility.
- Pending the test results, 4 additional residents and 5 staff members develop gastrointestinal signs and symptoms.
- One of 5 residents declined resulting in hospitalization.
The critical issue was not whether the resident ultimately tested positive. The facility must demonstrate that it recognized the risk and responded appropriately by implementing transmission-based precautions timely based on symptoms and not pending test results.
Failure to Cohort Residents During an Outbreak
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- A facility experienced an Influenza A outbreak.
- Instead of establishing appropriate cohorting and transmission-based precautions, residents continued to participate in communal activities, staff moved freely between affected and unaffected areas, and the facility did not have an effective outbreak-control plan.
- Additionally, residents who tested positive were cohorted with roommates who tested negative for Influenza A
- Two residents who were cohorted with roommates who tested positive developed signs and symptoms, declined, transferred to the hospital and later died.
- The facility was unable to demonstrate implementation of an outbreak control plan or provide evidence of the rationale for keeping residents in place without additional intervention.
Outbreak management should be tested before an actual outbreak occurs. Review policies and procedures related to outbreak management, specifically cohorting of resident’s guidance. Communicating with local health departments is crucial in determining additional steps to minimize the risk of transmission and further spread within the facility. The current CDC Viral Respiratory Pathogens Toolkit for Nursing Homes outlines recommendations related to resident placement and cohorting.
Improper Blood Glucose Monitoring Practices
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- A nurse performed a blood glucose test on multiple residents without appropriately cleaning and disinfecting the glucometer between use.
- The nurse also failed to practice appropriate hand hygiene and use a barrier when placing the glucometer down in each resident’s room.
- This practice created an opportunity for transmission of bloodborne or other infectious organisms to each resident.
While the facility had an appropriate glucometer use policy and procedure, the nurse failed to follow the outlined infection control practices, specifically related to cleaning and disinfection. To mitigate risk related to glucometer use, education should go beyond the classroom. Conducting direct observations of point of care use on a routine basis may increase compliance and reduce the chance of citation.
The best defense against high scope and severity infection control citations is building an infection prevention system that works every day, every shift, and with every resident.
Questions facility leadership should ask and review prior to the next survey include:
- Can staff demonstrate our infection control procedures without prompting?
- Can the infection preventionist show current surveillance data and explain the infection trends?
- Can we demonstrate that self-identified infection control deficiencies resulted in corrective action and follow-up?
- Can leadership identify our highest risk infection-control practices?
- If a serious infection control breach occurred this morning, would our facility recognize it quickly enough to prevent additional transmission?
Creating a culture where safe infection prevention and control practices are part of how every day care is provided is the goal.
Next Steps:
Make plans to join Proactive for these can’t miss educational sessions for more on this topic:
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- September 16-17, 2026 for a deep dive SNF Infection Preventionist Virtual Workshop. Using real-world scenarios, case studies, and interactive discussions, participants will develop the core competencies needed to effectively manage IPC programs, conduct surveillance, oversee antibiotic stewardship, and prepare for regulatory surveys.
- Beginning October 14, 2026, register to attend Proactive’s New! virtual series on Responding to Immediate Jeopardy. This 5-week intensive series offers long-term care professionals an in-depth understanding of the regulatory requirements and process involved when an Immediate Jeopardy (IJ) has been cited. Tips and strategies will be shared for writing an IJ Removal Plan and subsequent PoC, and for preparing for the IJ removal and revisit surveys that will follow. Sessions 3 through 5 will focus on the most commonly cited IJ issues: Abuse, Infection Control, and Accidents/Incidents with best practices for risk reduction in these areas.
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