Failure to Implement Contact Precautions and Provide PPE for Resident with CRE-Positive Wound
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures for a resident with multiple complex medical conditions, including a sacral pressure ulcer that tested positive for CRE (Carbapenem-resistant Enterobacteriaceae) and other organisms. Despite the resident's wound culture result indicating the need for contact isolation precautions, there was no order for transmission-based precautions or contact isolation in the physician order sheet, and enhanced barrier precautions were only noted for wounds and G-tube care. Observations revealed that the resident's room lacked required signage for transmission-based precautions, and there was no isolation setup or PPE supplies accessible at the room entrance. Staff members, including an LPN and a CNA, were observed entering the resident's room wearing only gloves and not donning gowns as required for contact precautions. The CNA provided direct care, including changing an incontinence brief and repositioning the resident, without proper PPE. Interviews with facility staff, including the infection preventionist and the director of nursing, confirmed awareness of the wound culture results and the necessity for contact isolation precautions, but these measures were not implemented in a timely manner. The infection preventionist acknowledged that the resident should have been transferred to a single room and that proper signage and PPE should have been in place immediately upon receipt of the culture results. The facility's own infection precaution guidelines require the use of transmission-based precautions, including contact precautions for residents with infections that can be transmitted by direct or indirect contact. The guidelines also specify the need for signage and PPE availability at the room entrance. The failure to follow these protocols resulted in staff providing care to the resident without proper PPE and without clear communication of the required precautions, creating the potential for cross-contamination among other residents assigned to the same staff.