Failure to Follow Contact Precautions for Resident with MDRO Infection
Penalty
Summary
A deficiency was identified when a nurse aide failed to follow proper infection prevention and control protocols while providing continence care to a resident with a documented multi-drug resistant organism (MDRO) infection in the urine. The facility's policy required the use of contact precautions, including wearing a gown, when caring for residents with conditions that increase the risk of environmental contamination and transmission, such as excessive wound drainage or incontinence. Despite these requirements, the nurse aide was observed providing care without wearing a gown. The resident involved was cognitively intact, required assistance with daily care, was frequently incontinent of bowel and bladder, and had a recent diagnosis of urinary tract infection with a positive urine culture for MDRO. Both the nurse aide and the Director of Nursing confirmed during interviews that the appropriate personal protective equipment, specifically a gown, should have been used during care. This failure to adhere to established infection control protocols was directly observed and confirmed through staff interviews.
Plan Of Correction
Nurse aide 4 was educated at the time of the survey on appropriate Personal Protective Equipment needed for resident R42's Enhanced Barrier Precautions. The Infection Control Nurse reviewed residents requiring Enhanced Barrier Precautions to ensure all line listing and signage was up to date. Staff was provided education regarding Enhanced Barrier Precautions and identification of residents requiring these precautions. The Infection Control Preventionist will complete random audits of care requiring Enhanced Barrier Precautions daily x5 for 2 weeks then weekly x 4, then monthly x2 months with results to Quality Assurance.