Failure to Use Required PPE for Resident on Contact Isolation
Penalty
Summary
The deficiency involves staff failing to follow the facility’s contact isolation and PPE requirements for a resident on contact precautions for a methicillin-resistant Staphylococcus aureus (MRSA) wound infection. The resident had multiple complex medical conditions, including chronic kidney disease, type II diabetes mellitus, chronic wounds, an indwelling urinary catheter, a colostomy, and multiple open surgical wounds to the abdomen and right lower extremity, placing her at increased risk for infection. Her care plan and physician orders specified single-room isolation with contact precautions for MRSA, and the facility’s posted signage outside her room directed all individuals to perform hand hygiene and don gloves and a gown before room entry, discarding them before exit. The facility’s written policy on contact precautions required hand hygiene prior to entering and exiting the room and mandated that all individuals entering the room use PPE appropriately, including gloves and a gown. Despite these requirements, surveyors observed multiple instances of noncompliance. An RN entered the resident’s room wearing only gloves to check blood sugar and administer insulin, during which the RN’s sweater touched the resident’s bedding. After being told by the IP nurse to wear proper PPE when entering the room, the RN re-entered the room again wearing only gloves to administer additional medications, and her sweater again contacted the resident’s bedding. Later, a CNA entered the same resident’s room without any PPE, touched the bedside table and bed rail, and interacted with the resident. The resident reported that staff do not always wear a gown and gloves when entering her room and stated she had an abdominal wound infection for which she was receiving antibiotics. The IP nurse confirmed that the resident was on contact isolation for MRSA of the abdominal wound and that the RN should have performed hand hygiene and donned both gown and gloves before entering the room.
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