Inadequate Infection Control for Resident with MDRO Risk
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically in the case of a resident identified as R35. The deficiency was observed when Employee E16 provided incontinence care to Resident R35 without wearing the appropriate personal protective equipment (PPE), specifically a gown, despite the resident being at risk for multi-drug resistant organism (MDRO) transmission. The facility's policy on Enhanced Barrier Precautions (EBP) requires the use of targeted PPE during high-contact resident activities to reduce the transmission of MDROs. However, the employee was only wearing gloves and was unaware that PPE was required for Resident R35, mistakenly believing that the enhanced barrier precaution sign on the door was only for the resident's roommate. Resident R35 entered the facility with a diagnosis of Type 2 diabetes and was assessed as having a diabetic foot ulcer. The resident required assistance and was dependent on staff for all activities of daily living due to paralysis and weakness on the left side. The resident's care plan indicated a risk for skin breakdown related to an actual pressure ulcer, and the clinical record included instructions to monitor for skin breakdown. However, the Kardex did not indicate that Resident R35 was on enhanced barrier precautions, contributing to the oversight in infection control measures.
Plan Of Correction
1. Resident R35 was placed on Enhanced Barrier Precautions. 2. IP or designee to conduct initial house audit to ensure all residents are identified for enhanced barrier precautions. 3. Infection Preventionist or designee will educate all staff on Enhanced Barrier Precautions. 4. Infection Preventionist or designee will conduct 5 random weekly audits x 12 weeks to ensure staff are compliant with EBP. 5. DON or designee to review the results of these audits at the monthly QAPI meeting x 3 months.