Failure to Implement Infection Control Program for Residents with MDROs
Penalty
Summary
The facility failed to implement an effective infection prevention and control program as required, specifically in the management of residents with multidrug-resistant organisms (MDROs). A resident tested positive for MRSA in both urine and a wound but continued to reside in a shared room with two other residents for approximately two weeks after the positive result. Facility policy and CDC guidelines require that residents with MDROs be placed in private rooms or cohorted with others with the same organism, especially when they have conditions that may facilitate transmission. Despite the availability of multiple empty rooms during this period, the resident was not moved to a private room until much later. The two other residents sharing the room had significant comorbidities and open wounds, making them particularly vulnerable to infection. One of these residents was later diagnosed with cellulitis and prescribed antibiotics, though no wound culture was performed to determine if MRSA was present. The decision to move residents between rooms was made by the Social Service Department without adequate communication with the Infection Preventionist (IP), who was not aware of the room changes or the availability of private rooms at the time. The IP acknowledged that, in retrospect, the resident with MRSA should have been placed in a private room immediately upon receiving the positive result. Interviews with facility staff, including the Nursing Unit Manager and Director of Nursing, confirmed that there was a lack of communication and coordination between departments regarding infection control measures and resident placement. The facility's own policies, as well as CDC guidelines, were not followed in this instance, resulting in the potential for the spread of infection among vulnerable residents. The deficiency was directly related to failures in communication, policy implementation, and timely action by the infection control team.