Failure to Implement Contact Precautions and PPE Use for Resident with MRSA
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures for a resident diagnosed with MRSA who was receiving IV antibiotics. Despite physician orders and care plan interventions specifying contact precautions and enhanced barrier precautions, staff did not consistently use required personal protective equipment (PPE) such as gowns and gloves, nor did they perform hand hygiene when entering the resident's room or providing care. Observations revealed that staff entered the resident's room, delivered meals, assisted with positioning, took vital signs, administered medications, and performed dressing changes without donning PPE or performing hand hygiene. There was also no contact isolation signage on the resident's door, and staff were unaware or misinformed about the resident's isolation status. The resident, who had a history of COPD, asthma, respiratory failure, and was on oxygen and fluid restriction, reported to surveyors that staff did not wear gowns or other protective equipment when assisting her. Staff interviews confirmed a lack of understanding regarding the need for contact precautions. Facility policy required gloves and gowns for contact precaution rooms, but this was not followed in practice, as evidenced by multiple staff failing to use PPE and perform hand hygiene during direct care activities, including invasive procedures such as IV site dressing changes and line flushing.