C. Diff in the hallways!

[dubspot]

I'm an RN at a long-term care facility. one of my residents was diagnosed with c. diff quite recently. we put this resident on isolation precautions and began flagyl. 2 days later, my DON asked me why my incontinent and confused patient was not allowed out of his room. I explained his dx, the order for contact precautions, and that he is incontinent. she stated thats not a good enough reason and that good "customer service" should be our goal, and now he is allowed to wander the halls and he oftentimes comes into direct contact with other residents, objects at the nurses station, etc. my question is: is there anything I can do to ensure that my resident with c. diff is receiving proper care without exposing my other residents to the infection? and is my DON really allowed to ignore a doctors order of isolation precautions just to achieve satisfactory "customer service"?

[SoldierNurse22, BSN, RN]

Do you have an infection control officer at your facility? I'd start there. I checked on a quick google search and it seems that if they're cleared to roam by IC, they should be OK.

As I would imagine this may be a common problem in your facility, you might consider putting this down in a policy. Remind that ridiculous DON of yours that it isn't good "customer service" to infect your healthy customers with C. diff for the sake of ambulating another patient.

Another source says this: http://www.sonoma.edu/users/k/koshar/n312c/PVHISOLATION.pdf

For ambulating in the hallway or leaving the room for PT, imaging, etc., have the patient wash hands prior to leaving the room, wear pajamas with a yellow gown and wear a diaper if incontinent.

At any rate, this patient (especially if confused) should not be allowed to ambulate alone. A nurse or tech should be with them for safety reasons if nothing else. Cleaning as you go isn't a bad idea if possible.

[dubspot]

Oh and the same patient is NPO because he failed his MBS horribly. But the same DON said he can eat whatever he wants because it's his patient right. I guess my problem is just with the DON in general. I don't feel comfortable with some of her nursing decisions.

[SoldierNurse22, BSN, RN]

Well, a competent patient does have the right to choose their diet. She's got a point there.

However, I can understand your feelings about this DON based on your original post. I wouldn't get warm fuzzy feelings from her, either.

[DoeRN]

Oh and the same patient is NPO because he failed his MBS horribly. But the same DON said he can eat whatever he wants because it's his patient right. I guess my problem is just with the DON in general. I don't feel comfortable with some of her nursing decisions.

The heck!! So make sure the DON is there to perform heimlich and clean up all the poop from all the other residents who will contract c-diff from this one patient. Only half kidding.

So tired of the customer service stuff.

Sent from my iPhone using allnurses.com

[MunoRN, RN]

The CDC doesn't have an explicit recommendation, but does recommend that CDI patients stay in their room "as much as possible". Because it's their home, LTC's do tend to be less militant about this, plus there really isn't any evidence that when basic precautions are followed that there is significantly more transmission risk when patients are allowed to leave their room. Basically, a patient should be assessed for their ability to follow basic hygiene rules (they should be capable of refraining from touching their perianal area and then touching objects in a shared area), and the ability to wash their hands properly before they leave the room. Something to keep in mind is that studies have shown at given time there are more asymptomatic but contagious C diff carriers than there are symptomatic carriers, so really if you might as well keep everyone in their room if you are keeping symptomatic C diff patient in their room.

I would agree that your DON might very well be failing to adequately understand the risks of CDI and it's potential for outbreak, but I'm not sure that a blanket "stay in your room" rule is the best either.

As for following the order, of course a nurse can refuse to carry out a Doctor's order.

[MunoRN, RN]

Oh and the same patient is NPO because he failed his MBS horribly. But the same DON said he can eat whatever he wants because it's his patient right. I guess my problem is just with the DON in general. I don't feel comfortable with some of her nursing decisions.

Patients who have not been found legally incompetent are allowed to refuse diet restrictions, as their nurse it's your job to make sure there right to refuse is honored, not to enforce the order.

[dubspot]

Yeah guess it just makes me upset. he is incompetent, and doesn't follow simple direction. He's very very combative, so something as simple as washing his hands is usually a huge ordeal.

[toomuchbaloney]

The OP indicates that the patient is confused and incontinent in the opening description.

That translates into the patient is not able to follow standard precautions necessary to prevent spread of C-Diff.

The family should come to assist the patient in safe ambulation out of his room and the staff should accomplish that at least once per shift as well. Otherwise, he is in his room unless adequately supervised in order to protect the other residents.

Will that DON accept personal responsibility when there is an outbreak of C-Diff in the facility and a fragile elderly resident is hospitalized or dies?

[dubspot]

Customer service > patient care

[eeffoc_emmig]

When I worked in LTC, I had a resident that was a lot like the OP's. He was confused and had c-diff. Our administrator would not allow us to keep him isolated because it upset his daughter to "see Daddy locked up". Almost every resident ended up with c-diff. All because customer service comes first. I can't wrap my mind around that concept.

[NayRN]

the hospital i used to work at used to bug me with this as well. we had c diff and mrsa patients going out to smoke. the thing is that you can educate until you turn purple, but a patient can claim that they were falsely imprisoned if you won't let them out of their room. you can't restrain them, you can't legally keep them in their room. there are a lot of legal issues with this one, but i tend to agree-the right of one patient to freedom of movement shouldn't trump everyone else's right to a clean environment.