Failure to Use PPE and Hand Hygiene During Contact Precautions
Penalty
Summary
A deficiency occurred when the Director of Nutrition Services entered the room of a resident on contact transmission-based precautions for MRSA without donning personal protective equipment (PPE) or performing hand hygiene before entering or after exiting the room. The resident had a medical history that included an infection following a procedure, acquired absence of the right leg above the knee, muscle weakness, and a current MRSA infection. Physician orders required contact precautions for this resident, and signage indicating these precautions, along with a PPE cart, was present outside the room. During the evening meal delivery, the Director of Nutrition Services obtained a Styrofoam cup from another area, poured hot water for tea, and delivered it to the resident without following the required PPE and hand hygiene protocols. The Director later confirmed in an interview that he did not adhere to the contact isolation guidance. Facility policy required staff to wear gloves and gowns and perform hand hygiene when entering and exiting rooms under contact precautions, but these procedures were not followed in this instance.