Failure to Use Appropriate PPE in Contact Precaution Room
Penalty
Summary
The facility failed to adhere to appropriate infection control practices by not ensuring that staff wore a personal-protective gown while entering a room under Contact Precautions. This deficiency was observed in the case of a resident diagnosed with Methicillin Resistant Staphylococcus Aureus Infection, a multi-drug resistant organism. During the survey, a registered nurse was seen entering the resident's room wearing gloves but not a gown, despite the presence of a sign outside the room indicating the requirement for both gloves and a gown under Contact Precautions. The nurse justified her actions by stating she was not providing direct care, only shutting off a pump alarm. However, the facility's policy on Transmission-Based Precautions, revised in April 2024, clearly states that a gown should be worn whenever there is potential contact with the resident or contaminated surfaces. The Infection Preventionist confirmed the resident was on Contact Precautions, and the Director of Nursing acknowledged the need for staff education on the proper protocol for entering rooms under such precautions.
Plan Of Correction
F880- Infection Control What corrective action will be accomplished for those residents affected by the deficient practice? Educated RN #1 on the Policy for Transmission Based Precautions. With emphasis on wearing proper PPE when entering room and providing care on Resident #320 on NJ Ex Order 26.4(b)(1) Precautions. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents on Contact Isolation Precautions have the potential to be affected by this alleged deficient practice. Unit managers checked other residents on Contact Precautions, and no concerns were identified. What measures will be put into place or what systemic changes will be made to ensure the deficient practice will not recur? The policy on Infection Prevention and Control was reviewed. Nurse Educator began education on December 16, 2024 to RN/LPN/CNAs/Therapists on policy for Transmission Based Precautions. The staff members were educated on the importance of wearing proper PPE when entering and giving care for resident on Contact Isolation Precaution. How will the corrective action be monitored to ensure the deficient practice will not recur? Audits will be conducted by Nursing Administration on wearing proper PPE when entering and giving care for residents on Contact Isolation Precautions. Audits will be conducted weekly x4, then monthly x3. The results of the audit will be reviewed at the monthly QAPI Committee chaired by the facility administrator.