Inspection Detail

Inspection: 125716407 - Sierra Nevada Memorial Hospital

Inspection Information - Office: Sacramento District Office

Investigation Summary

On December 19, 2003, an employee was taking care of several patients in 2 North Medical Oncology Unit, including one known to have an MRSA infection, but this patient was in contact isolation and the employee wore gloves when working in that patient's room. However, also at this time, the employee worked in non-isolated patients' rooms and did not wear gloves when performing certain duties that did not involve exposure to blood or OPIM, such as setting up the bed tray. At this time, she had dry, rough or recently healed skin under her right thumbnail. She was working with an IV in a patient's room when she discovered that her right thumb had cracked and begun to bleed. She immediately washed her hands and put a band-aid on the cracked skin but she did not know how long her skin had been cracked. She continued to work wearing a band-aid and gloves. On December 20, 2003, she received a call from the laboratory informing her that one of her non-isolated patients was infected with MRSA, so she used contact isolation precautions to isolate him. Apparently, the patient's physician had ordered lab tests due to a persistent productive cough that was not getting better. On January 4, 2005, her right thumb and wrist had begun to swell and become very painful so that she was unable to work. She went to her own physician who treated it with an antibiotic and it started to get better, but then got worse again. Then tests were run on her and they found that she had been infected with MRSA. It is likely that she was infected with MRSA on the December 19, before she realized that the skin on her thumb was cracked. She informed her supervisor about her infection on January 9, 2004, the day she was hospitalized. She was discharged on January 16, 2004.

Keywords: THUMB, INFECTION, SKIN