Failure to Maintain Contact Isolation Precautions for Resident with Infected Pressure Ulcers
Penalty
Summary
A deficiency occurred when staff failed to maintain contact isolation precautions for a resident with multiple medical conditions, including infected pressure ulcers. The resident was documented as severely cognitively impaired and completely dependent on staff for all activities of daily living. Physician orders required contact isolation precautions due to a wound infection, and appropriate signage and personal protective equipment (PPE) were present at the resident's room. Despite these measures, an LPN entered the resident's room without donning a gown or gloves to sanitize the bedside table, using bare hands to move the table and then exiting the room without performing hand hygiene. The LPN then handled wound dressing supplies outside the room, which were later used on the resident's infected pressure ulcers. The Director of Nursing confirmed that proper PPE should have been used and that the wound supplies were contaminated as a result of these actions. Facility policy required contact precautions for residents with infections that could be transmitted through direct or indirect contact.