Failure to Implement Timely Contact Precautions for CRPA-Positive Resident
Penalty
Summary
The facility failed to implement proper infection control precautions in accordance with its policy and procedure when a resident tested positive for carbapenem-resistant pseudomonas aeruginosa (CRPA) on March 28, 2025. The resident, who had a history of respiratory failure with tracheostomy and resistance to carbapenems, was not placed on contact isolation immediately after the positive sputum culture result was received. Although the medical doctor was notified and ordered no antibiotics, there was no documentation that the Infection Preventionist (IP) was informed of the CRPA result at that time. The resident remained without appropriate contact isolation for nearly a month, despite facility policy requiring immediate implementation of contact precautions for CRPA cases. Interviews with staff revealed that the registered nurse who received the culture result did not notify the IP or document the result in the progress notes. The IP only became aware of the CRPA result on April 22, 2025, after which the resident was moved and placed on contact and droplet precautions. The Director of Nursing confirmed that the culture result was received but not reviewed or acted upon until almost a month later. Facility policy, which adheres to CDC guidelines, mandates that residents colonized or infected with CRPA be placed on contact precautions to prevent transmission.