Roger Young is a 43-year-old male hospitalized following a motor vehicle accident in which he was an unrestrained driver. Roger sustained a left femur fracture which required an open reduction and internal fixation. Roger is alert and oriented and requires minimal assistance with transfers and ambulation using a rolling walker secondary to a 50% weight bearing restriction on the left lower extremity. His surgical incision has 27 intact staples with scant serosanguinous drainage, is well approximated, and is open to air. His roommate is Joe Garrett, an 82- year-old male hospitalized following a right hemispheric CVA. Joe is a bit forgetful, and Roger often reminds Joe not to get up on his own, helps him adjust his bedding, or hands him personal items to discourage him from crawling out of bed unassisted. Joe had an indwelling urinary catheter, inserted in the Emergency Department upon admission, which was removed on Monday, two days ago. Since then, Joe has been voiding frequent, small amounts with occasional incontinent episodes. The physician was made aware and ordered a urine culture and sensitivity, which was collected and sent to the lab for processing on Wednesday evening. On Friday evening, the culture report was received via print from the lab just as the RN was leaving the unit for her dinner break. The RN quickly reviewed the report and called the physician with a result of >100,000 E. coli. Orders for antibiotic therapy were obtained and the medication was initiated. The culture report also indicated in the comment section that the specimen was positive for extended spectrum beta-lactamase (ESBL), a multidrug resistant organism. The nurse failed to note the comment and no contact or isolation precautions were implemented. The physician assistant (PA-C) reviewed and signed off on the report on Saturday morning and also overlooked the comment. Roger, with his fresh surgical incision, remained in the room coming into close contact with Joe, his bedding, and his personal items, all contaminated with ESBL. Staff continued to care for Joe utilizing standard precautions, but no additional personal protective equipment (PPE) beyond gloves. On Monday morning, the Infection Preventionist noted the results during routine surveillance. Contact precautions were implemented and Joe was moved to a private room. Roger’s day of discharge finally arrived. Roger’s girlfriend, Donna, came to take him home. Donna was a frequent visitor during Roger’s hospitalization, and was extremely supportive. She has even applied for Family Medical Leave (FMLA) in order to function as his primary caregiver during his convalescence. Unbeknownst to the staff, Donna and Roger have also been taking advantage of the privacy and alone time since Joe was moved into isolation, and they have resumed intimate behaviors. While they wait for the nurse to come in and review Roger’s discharge instructions, Donna excuses herself to use the bathroom three times. Upon their return home, the frequency continues, along with occasional bladder spasms and burning with urination. Roger encourages Donna to see her primary care physician, where she is diagnosed with a urinary tract infection and started on antibiotics. Three days later, Donna receives a call from her physician informing her that her urine culture has come back positive for ESBL.
DISCUSSION QUESTIONS 

1. What are the facts of this case?
2. Review the quality improvement tools and select the appropriate one to analyze this problem.
3. What are the top three management issues in this case?
4. What are the legal and ethical obligations a health care organization has to its patients and families and how do they apply to this case?
5. Who should be held responsible for addressing these problems?
6. Is the health care facility responsible for Roger’s infection? If no, why not? If yes, what obligations does the facility have to Roger?
7. Is the health care facility responsible for Donna’s infection? If no, why not? If yes, what obligations does the facility have to Donna?