Failure to Adhere to Contact Precautions for Resident with MRSA Infection
Penalty
Summary
A deficiency was identified when the facility failed to maintain an effective infection prevention and control program as required by federal regulations. Specifically, a resident with a diagnosis of methicillin-resistant Staphylococcus aureus (MRSA) infection in a foot wound was placed on contact precautions, as documented in the care plan and supported by multiple physician orders. The orders specified the use of enhanced barrier precautions, including the use of personal protective equipment (PPE) such as gloves, gowns, and face masks during resident care activities. The facility's policies also required staff to adhere to these precautions and to report any breaches in infection control practices. Despite these requirements, observations revealed that staff did not consistently follow the prescribed infection control measures. During one observation, a registered nurse supervisor exited the resident's room wearing only a mask, which was then improperly disposed of by crumpling it and placing it in a pocket, without performing hand hygiene. Additionally, the same nurse was observed providing care to another resident without wearing any PPE. Interviews with the staff involved confirmed that they were not wearing gowns while providing wound care to the resident on contact precautions, and acknowledged that this was a breach of protocol that could lead to contamination. The Director of Nursing Services confirmed that signage was present on the resident's door indicating the required PPE for contact precautions, and stated that all staff should wear appropriate PPE before entering rooms of residents on contact precautions. However, there was no documented evidence of a physician's order to discontinue contact precautions for the resident, and the required infection control practices were not followed during the observed care activities. This failure to adhere to established infection prevention and control protocols resulted in a deficiency citation for the facility.