Failure to Follow Contact Precautions During Wound Care for MRSA-Positive Resident
Penalty
Summary
Staff failed to follow proper Contact Precautions during wound care for a resident with a history of stroke, anxiety, and depression, who had recently returned from the hospital with abscesses that tested positive for MRSA. Hospital discharge orders specified daily dressing changes and the use of Contact Precautions. During an observed dressing change, the registered nurse did not wear a gown, as required, and only donned gloves. There was no visible signage on the outside of the resident's door indicating Contact Precautions, nor was there a PPE cart available outside the room. The only sign present was inside the room and difficult to see due to poor lighting. When questioned, the nurse acknowledged that a gown should have been worn and attributed the oversight to the lack of visible signage and PPE cart. The infection preventionist confirmed that signage and PPE should have been placed outside the room and that a gown was required for the procedure. The failure to follow established infection control protocols was directly observed and confirmed through staff interviews and record review.