Failure to Follow Contact Isolation Protocols for Resident with ESBL/VRE Infection
Penalty
Summary
Staff failed to follow the facility's transmission-based precautions policy for a resident with a documented ESBL/VRE urinary tract infection who was under contact isolation. On two separate occasions, staff entered the resident's room without donning the required personal protective equipment (PPE). One CNA entered the room with only a surgical mask, did not wear gloves or a gown, and did not perform hand hygiene before entry, despite signage indicating contact isolation. The CNA handled items in the room and assisted the resident with a meal before exiting and using hand sanitizer. The CNA stated they were unaware of the type of isolation required for the resident. A nurse also entered the same resident's room wearing only gloves, omitting the gown as required by the posted contact isolation sign. The nurse was unable to confirm the resident's current isolation status and stated confusion regarding whether the resident was on contact isolation or enhanced barrier precautions. The infection prevention nurse later confirmed that the resident was on contact isolation and that staff are expected to don gown, mask, and gloves prior to entry. The resident's care plan did not address contact isolation, despite physician orders and infectious disease notes specifying the need for such precautions.