Failure to Ensure Staff Competency in Contact Precautions for MDROs
Penalty
Summary
Facility staff failed to demonstrate competency in implementing proper infection prevention techniques for residents requiring contact precautions, despite having received annual education and competency training. The facility's policy and competency documents clearly differentiate between Enhanced Barrier Precautions (EBP) and Contact Precautions, specifying that for residents with multi-drug resistant organisms (MDROs) such as MRSA and VRE, staff must don gown and gloves upon entering the room and perform hand hygiene upon exit. However, multiple staff members, including nursing assistants, a maintenance assistant, a certified medication technician, and a laundry aide, were observed entering a resident's room on contact precautions without the required personal protective equipment (PPE) or failing to perform hand hygiene as required. The resident involved had been readmitted with diagnoses of MRSA in the nares and VRE in the rectum, and was placed on contact precautions as indicated by signage on the resident's doorway. Despite this, staff were observed entering the room without donning gowns or gloves, and in some cases, not performing hand hygiene upon exiting. These observations occurred over several days and involved staff from various departments, all of whom had attended the facility's annual infection prevention competency training. Interviews with facility leadership, including the DON, Infection Preventionist, and Assistant DON, revealed a lack of understanding regarding the distinction between EBP and contact precautions. Leadership incorrectly stated that PPE was only necessary when providing direct care, which is contrary to both facility policy and the posted contact precaution signage. This confusion and failure to follow established protocols resulted in staff not implementing the required precautions for a resident with active MDRO infections.