Failure to Implement Contact Precautions for Resident with ESBL
Penalty
Summary
The facility failed to ensure that transmission-based precautions were implemented as ordered for a resident who tested positive for Extended-Spectrum Beta-Lactamases (ESBL) in their urine. The resident had a physician's order for contact precautions, including the use of gloves, gown, eye protection, and mask for a specified period. Despite clear signage and the availability of personal protective equipment (PPE) at the resident's room, a Certified Nursing Assistant (CNA) was observed entering the room, delivering a lunch tray, and assisting with a transfer without donning the required PPE. During the transfer, the CNA's and resident's clothing came into contact, and the CNA only donned PPE after realizing the oversight when returning to the room. The CNA also removed the lunch tray from the room without using a biohazard bag, as required for contact isolation protocols. Interviews with the CNA, the Treatment Nurse, and the Administrator confirmed that the facility's process for contact isolation includes signage, PPE availability, and staff notification, with the expectation that staff don PPE before entering the room. Facility policies reviewed indicated that staff and visitors are required to wear gloves and gowns upon entering rooms under contact precautions. The deficiency was identified through direct observation, record review, and staff interviews, demonstrating a failure to follow established infection prevention and control protocols for a resident with a multidrug-resistant organism.