Failure to Follow EBP, Contact Precautions, and Hand Hygiene for Resident With MRSA Wound
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain an effective infection prevention and control program for a resident with a history of a MRSA-infected wound on the right flank. The resident was an older male with multiple comorbidities, including traumatic brain injury, hemiplegia, chronic kidney disease, dysphagia, chronic pain, and a documented bacterial infection. His MDS showed mild to moderate cognitive impairment and total dependence on staff for ADLs, including transfers with a mechanical lift. The care plan identified an actual impairment to skin integrity related to cellulitis and infection of soft tissue in the right breast/axilla area, with interventions to monitor and document the wound and signs of infection. Physician orders documented contact precautions and later Enhanced Barrier Precautions (EBP) for a MRSA infection to a wound on the right flank, with orders specifying the use of gown and gloves during high-contact resident care activities. Video observations over several dates showed repeated failures by unidentified staff to follow contact precautions and EBP requirements when providing care to this resident. Staff were observed wiping a fungal area later diagnosed as MRSA and then using the same wipe on the rest of the resident’s body. Staff applied facial cream and checked the right-side wound while wearing only gloves and masks, without gowns. During incontinence care, staff used gloves but did not change them appropriately, applied patches without changing gloves, placed a trash can from the floor onto the resident’s sheets, and then used the same contaminated gloves to make the bed. Staff repeatedly failed to wear gowns during incontinence care, clothing changes, and wound care, and did not clean or disinfect surfaces and equipment such as bedside tables, wound care trays, markers, and mechanical lifts after use in the resident’s room. Additional observations showed that staff did not perform hand hygiene between glove changes or after glove removal, contrary to facility policy. One nurse used a marker stored in his pants on the resident’s wound bandage and returned it to his pants without cleaning it, did not change gloves, and left the room carrying trash and a tray without disinfecting them. Another nurse performed wound care on the bedside table without wiping it down afterward and touched the bed remote, bedside table, and drinking glass with contaminated gloves. On a later observation date, the resident’s door lacked an EBP sign despite active EBP orders, and a CNA provided peri-care without a gown and without handwashing or hand sanitizer between multiple glove changes while cleansing the peri-area and buttocks, applying skin barrier, and repositioning the resident. The same CNA also failed to disinfect the mechanical lift before removing it from the resident’s room. Interviews with the CNA, ADON, and ADM confirmed that staff had been trained on infection control, hand hygiene, and EBP, and that facility policies required hand hygiene before and after resident contact, between glove changes, and after glove removal, as well as appropriate use of gowns and gloves for residents on contact precautions.
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