Failure to Follow Infection Control Precautions
Penalty
Summary
The facility failed to adhere to enhanced barrier precautions (EBP) for two residents, R22 and R315, and did not implement proper interventions for a Covid-positive resident, R34. Resident R22, who had renal failure and required dialysis, did not have EBP orders for indwelling medical devices as required. During an observation, a registered nurse failed to properly don a gown when checking the resident's AV fistula, indicating a lack of familiarity with the gowning procedure. Resident R315, diagnosed with breast cancer and secondary bone cancer, was placed under isolation-contact and droplet precautions due to respiratory symptoms. However, the care plan did not include necessary interventions for these precautions. An observation revealed that a nurse aide assisted the resident without wearing a gown or N95 respirator, as required by the physician's orders, and the signage on the resident's door was incorrect. Resident R34, who tested positive for Covid-19, was supposed to be under airborne contact isolation. However, the resident's door was left open, and a nurse aide was observed inside the room without the appropriate personal protective equipment (PPE), including an N95 mask, gloves, or gown. The signage on the door only indicated airborne precautions, and the infection preventionist confirmed the facility's failure to follow the required precautions for these residents.
Plan Of Correction
Residents R-22, R315, and R34 have all experienced resolution of their condition and are now not needing any precautions. All nursing staff (RNs, LPNs, CNAs, and Unit Managers) will receive additional training on the types and reasons for transmission-based precautions as well as the PPE required from the In-Service Director or designee. Additionally, staff will demonstrate their ability to effectively don and doff a gown. The Director of Nursing, In-Service Director, or designee will observe 10 random resident staff encounters weekly for three weeks to ensure proper PPE. This includes donning of gowns. Additionally, 5 random encounters will be observed for three weeks. Any deficient practice will be immediately corrected. All data will be forwarded to the QAPI committee and the need for additional monitoring will be determined by the committee.