Failure to Use Required PPE for Resident on Contact Isolation
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff failed to implement required contact isolation precautions for a resident with an ESBL-positive urinary tract infection. During an observation in the resident’s room, a CNA and an RN were present without wearing an isolation gown or gloves, despite a contact isolation sign posted outside the room. Both staff members were observed holding the resident’s wheelchair with bare hands while preparing to transfer the resident back to bed. In subsequent interviews, the CNA and RN each stated they had forgotten the resident was on contact isolation and acknowledged that staff should wear an isolation gown, gloves, and mask before entering the room when a resident is on contact precautions. Record review showed the resident had been admitted and readmitted to the facility with diagnoses including UTI, ESBL, depression, and COPD. The MDS indicated the resident had moderately impaired cognitive skills and required substantial/maximal assistance with transfers, bathing, and toileting, and was incontinent of urine. The resident’s care plan, dated two days prior to the observation, documented that the resident was on isolation precautions related to ESBL, with interventions including maintaining contact isolation precautions. An SBAR form and urine culture dated the same day confirmed ESBL in the urine and that the physician had been notified. The Infection Preventionist Nurse and DON both stated that, based on the resident’s ESBL status and facility policy on transmission-based precautions, staff entering the room should perform hand hygiene and wear gown and gloves to prevent cross contamination, and that not practicing contact precautions could cause spread of infection to other residents and result in an outbreak. The facility’s written policy on transmission-based precautions required gown and gloves upon entering rooms of residents on contact precautions.
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