F0880

D

Failure to Follow Contact Precautions for Resident on MRSA Isolation

Carmichael, California Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

A deficiency occurred when a contracted phlebotomist failed to follow the facility’s contact precaution requirements while providing care to a resident with a documented Methicillin Resistant Staphylococcus Aureus (MRSA) sacral wound infection. The resident had a physician’s order dated 2/9/26 for contact precautions every shift, which required the use of gloves and a gown for all room interactions. During an observation and concurrent interview on 2/19/26 at 8:46 a.m., the contracted phlebotomist drew blood from this resident without wearing a gown. After leaving the room, the phlebotomist touched phlebotomy equipment without changing gloves or performing hand hygiene, then returned to the resident to continue the blood draw.

When questioned, the contracted phlebotomist was unable to state what constituted contact precautions or whether a gown was required for direct care. After this interaction, the phlebotomist entered another resident’s room to draw blood without cleaning the equipment. The Infection Preventionist later confirmed that the resident was on contact precautions and that staff performing direct care, such as blood draws, should wear a gown. The DON stated that contact precautions should be followed by all staff, including contracted staff. The facility’s written policy on Isolation - Categories of Transmission-Based Precautions, revised 10/18, specified that staff and visitors will wear gloves and a disposable gown upon entering the room of a resident on contact precautions, change gloves after contact with infective material, remove gloves and perform hand hygiene before leaving the room, and remove the gown before leaving while avoiding contact of clothing with potentially contaminated surfaces.