Failure to Implement Enhanced Barrier Precautions and Hand Hygiene for Resident with MRSA and Chronic Wounds
Penalty
Summary
The facility failed to implement and follow Enhanced Barrier Precautions (EBP) and proper hand hygiene protocols for a resident with non-healing wounds and a history of Methicillin Resistant Staphylococcus Aureus (MRSA). The resident's care plan identified the need for EBP due to chronic wounds and MRSA, but did not specify which high-risk activities required EBP or detail the necessary precautions. Observations revealed that staff entered the resident's room without performing hand hygiene, did not use gowns or masks as required, and only donned gloves before providing incontinence care and assisting with transfers. After providing care, staff either failed to perform hand hygiene or changed gloves without cleaning their hands, and then continued to handle the resident and their environment. Signage indicating the need for EBP was posted outside the resident's room, but there was no personal protective equipment (PPE) cart available, and staff were unaware of the requirement to use EBP during personal care activities. Both nursing assistants involved in the care stated they did not know EBP was necessary for the resident and confirmed the absence of a PPE cart. They also described disposing of PPE in the resident's room and admitted to not performing hand hygiene at key points during care. The LPN assigned to the resident confirmed that EBP should be used for all personal care due to the resident's wounds and MRSA history, and the DON stated that facility policy required EBP and hand hygiene for such cases. Facility policies reviewed indicated that EBP should be used for residents with wounds or MDROs during high-contact care activities, and that hand hygiene is required before and after resident contact, between glove changes, and upon entering and exiting rooms. Despite these policies, the observed care did not comply with established protocols, resulting in a failure to reduce the risk of infection transmission for the resident and others.