Failure to Follow Contact Precaution Protocols for Resident with MDRO UTI
Penalty
Summary
Staff failed to follow established infection control standards for transmission-based precautions for a resident admitted with a diagnosis of pseudomonas aeruginosa urinary tract infection, a multi-drug-resistant organism. Physician orders and facility policy required contact isolation, including the use of personal protective equipment (PPE) such as gowns and gloves upon entering the resident's room. Observation revealed that a CNA entered the resident's room without donning any PPE, despite clear signage and readily available PPE at the door. The CNA handled the resident's personal belongings on the bedside table and then exited the room without wearing gloves or a gown. Interviews with the CNA, LPN supervisor, and Director of Nursing confirmed that staff were expected to wear appropriate PPE when entering rooms under contact precautions. The CNA stated a misunderstanding of the requirements, believing PPE was only necessary when directly caring for the resident, not when entering the room or handling items. Facility policy and posted signage both specified that gloves and gowns must be worn upon entry to the room, regardless of the nature of the visit, to prevent the spread of infection.