Failure to Adhere to Contact Isolation Protocols for Residents with ESBL and MRSA
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple staff not adhering to contact isolation protocols for two residents with communicable infections. One resident, a severely cognitively impaired female with a history of urinary tract infection (UTI) and extended-spectrum beta-lactamase (ESBL) in her urine, was placed on contact isolation per physician order. Despite a sign posted on her door, both an LVN and a CNA entered her room and provided care, including blood sugar checks, insulin administration, and personal care, without donning the required gown and gloves. The CNA also failed to properly dispose of contaminated linen, and both staff members acknowledged their lapses, citing reasons such as forgetting the precautions or not seeing the necessary PPE supplies nearby. Another resident, who was cognitively intact and diagnosed with MRSA in her urine, was also placed on contact isolation. However, she was observed participating in group activities and socializing with other residents outside her room. Interviews revealed that she had not been adequately educated about the need to remain in her room or the nature of her infection, and her care plan did not initially address contact isolation or refusal to comply with isolation protocols. Facility leadership, including the ADON and DON, provided inconsistent information regarding the expectations for residents on contact isolation, with some staff unsure of policy details and others stating that residents should be encouraged to stay in their rooms and that refusals should be documented and care plans updated accordingly. Record reviews confirmed that both residents had physician orders for contact isolation and that facility policies required the use of gowns and gloves for staff entering rooms of residents on contact precautions. Observations and interviews demonstrated that these policies were not consistently followed, and that signage, PPE availability, and staff education were insufficient to ensure compliance. These failures were directly observed by surveyors and confirmed through staff interviews and record reviews.