Failure to Implement Proper Contact Precautions for Resident with MRSA
Penalty
Summary
A deficiency was identified when a resident with a history of MRSA septic arthritis, bacteremia, and a PICC line for intravenous antibiotics was not placed on proper contact precautions. The resident had undergone surgical cleaning of both ankles, with the left foot confirmed to have MRSA. Despite the presence of a PPE cart in the room and a magnet indicator on the doorframe, there was no signage specifying the type of transmission-based precautions required. The resident's medical records indicated orders for both Enhanced Barrier Precautions (EBP) and Contact Precautions due to wounds and the PICC line, and the care plan included interventions for EBP related to these conditions. Interviews with staff revealed confusion and lack of clarity regarding the implementation and distinction between EBP and Contact Precautions. An LPN was unable to clearly differentiate between the two types of precautions or specify the required PPE for each. The Director of Rehabilitation was unaware that the resident was on any transmission-based precautions and allowed the resident to participate in therapy sessions in the gym, stating that if the wound was contained, gym attendance was permitted. The DON confirmed that a number 6 magnet was used to indicate EBP, but that Contact Precautions would require additional signage, which was not present for this resident. Facility policies and CDC guidance reviewed during the survey specified that residents with MRSA infections should be placed on Contact Precautions, with clear signage and appropriate use of gowns and gloves upon room entry. The lack of proper signage, inconsistent staff knowledge, and failure to implement the correct precautions for a resident with an active MRSA infection led to the deficiency. The resident was observed participating in group therapy without the required precautions in place, further demonstrating the facility's failure to maintain an effective infection prevention and control program.