Failure to Implement Contact Precautions for Resident with Uncontained MDRO Drainage
Penalty
Summary
A deficiency occurred when the facility failed to implement appropriate contact isolation precautions for a resident with a multi-drug resistant organism (MDRO) infection, specifically Acinetobacter Baumannii Carbapenem Resistant, whose wound drainage was not contained. The resident had a complex medical history including cellulitis, morbid obesity, congestive heart failure, chronic kidney disease, and lymphedema, and was admitted for skilled care with ongoing wound management. Despite orders for enhanced barrier precautions, the resident was not placed on contact precautions even after the wound culture confirmed the presence of a highly resistant organism with uncontained drainage. Staff interviews and record reviews revealed that the resident's wound was actively draining, resulting in wet footprints and contaminated surfaces in therapy and common areas. Staff used gloves and sometimes gowns during therapy, but there was no consistent use of contact precautions, no dedicated equipment, and no requirement for staff to gown and glove upon entering the resident's room. The resident was observed to move independently through the facility, leaving wet areas from the wound drainage, indicating a failure to contain infectious material and prevent potential transmission. Additionally, the facility did not promptly notify the local health department as required after the identification of the MDRO, and there was confusion among staff regarding the implementation and discontinuation of enhanced barrier versus contact precautions. Documentation inconsistencies were noted, with forms indicating contact precautions were in place when only enhanced barrier precautions had been implemented. The infection control oversight was in transition, with responsibilities shifting between staff, contributing to the lack of appropriate infection prevention measures for the resident.