Failure to Implement Contact Precautions for Resident with MDROs
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically regarding the implementation of contact precautions for a resident with active Methicillin-resistant Staphylococcus Aureus (MRSA) in the nares and Vancomycin Resistant Enterococci (VRE) in the rectum. The resident, who had severely impaired cognition, was ambulatory with supervision, incontinent of stool, and had recently experienced loose stools. Facility policy required staff to don gown and gloves before entering the resident's room and to perform hand hygiene upon exit, as indicated by signage on the resident's door and the presence of a PPE bin outside the room. Despite these requirements, multiple staff members, including nursing assistants, maintenance, housekeeping, medication technician, and laundry staff, were observed entering the resident's room without appropriate PPE, such as gowns and gloves, and in some cases, failed to perform hand hygiene after leaving the room. Staff were seen touching shared surfaces like privacy curtains and beds, and transporting items between rooms without following proper infection control procedures. Interviews with the DON and Infection Preventionist revealed a misunderstanding of the facility's policy, as they believed PPE was only necessary for direct care, not for all room entry, which contradicted both facility policy and posted instructions.