Failure to Follow Contact Precaution Protocols for Resident with MDROs
Penalty
Summary
A deficiency occurred when a nurse aide failed to follow the facility's infection prevention and control policies for contact precautions. The aide entered the room of a resident who was on contact precautions for multiple multidrug-resistant organisms (MDROs), including ESBL, E. coli, and MRSA, without performing hand hygiene or donning the required personal protective equipment (PPE) such as gown and gloves. The aide delivered the resident's breakfast tray, leaned against the bed, and exited the room without washing her hands. The aide later stated she was confused about the type of precautions required and did not realize the resident was on contact precautions, mistakenly believing enhanced barrier precautions applied instead. Interviews with facility staff, including a nurse, physician assistant, director of nursing, and the administrator, confirmed that the resident was the only one in the facility on contact precautions and that staff were expected to read and follow the isolation signage posted on the resident's door. The director of nursing acknowledged that staff sometimes did not read the signs and that the facility had not had a contact precaution isolation in some time. The failure to adhere to posted infection control protocols resulted in a breach of the facility's infection prevention and control program.