Failure to Enforce Contact Precautions for Outside Vendor
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when an outside vendor ultrasound technician (UT) failed to follow posted contact precaution requirements while providing bedside care to a resident. A sign outside the resident’s room clearly indicated Contact Precautions and instructed staff and visitors to wear a gown, gloves, and mask prior to entering, and to perform hand hygiene upon entry and exit. The UT was observed at the bedside using an ultrasound machine with the probe touching the resident’s arm while wearing only gloves, without a gown or mask, and remained in the room for approximately five minutes. The UT later re-entered the room without performing hand hygiene or donning new gloves. Record review showed the resident had been admitted with diagnoses including metabolic encephalopathy and had a BIMS score of one, indicating severely impaired cognitive status. A physician’s order dated two days prior to the observation placed the resident on contact precautions. Interviews with an LVN, a CNA, the Infection Preventionist, and the DON confirmed that the resident was on contact precautions and that facility protocol required gown, gloves, mask, and hand hygiene for all individuals entering the room. They also stated that the UT should have been instructed on and should have followed the PPE requirements. Review of the facility’s policy on initiating transmission-based precautions indicated that signage is used to inform staff of the type of CDC precautions and PPE instructions, and that protective equipment such as gloves, gowns, and masks is to be maintained outside the resident’s room so anyone entering can apply the appropriate equipment.
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