Failure to Follow Contact Isolation and PPE Requirements for MDRO-Positive Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow established infection prevention and control guidelines, specifically contact isolation requirements, for a resident with a multidrug-resistant organism (MDRO). CDC guidance dated July 12, 2022, and CMS infection prevention and control guidance effective April 1, 2024, call for the use of Enhanced Barrier Precautions and appropriate PPE, including gowns and gloves, during high-contact care activities for residents with MDROs or certain risk factors. The facility’s own transmission-based precautions policy dated February 27, 2026, requires staff to wear gloves and a disposable gown upon entering the room of a resident on contact precautions and to remove them before leaving the room. Resident 7’s admission MDS dated February 24, 2026, showed the resident was cognitively intact, required assistance with daily care needs, and had a medical diagnosis including a urinary tract infection. A physician order dated February 21, 2026, directed that the resident be on contact isolation for an MDRO diagnosis. On observation, a nurse aide was seen assisting this resident into the bathroom without wearing an isolation gown, contrary to the facility’s contact isolation policy. The nurse aide acknowledged she should have been wearing a gown, and an LPN confirmed the resident had orders for contact isolation for MDRO. The DON also confirmed that the nurse aide should have had a gown on when providing care to this resident.
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