Infection Control Lapses in Droplet Precautions
Penalty
Summary
The facility failed to implement proper infection control practices for two residents on droplet precautions. The facility's infection control policy, last reviewed in April 2024, outlines the need to prevent and control the spread of communicable diseases and establish guidelines for transmission-based precautions. However, observations revealed that these guidelines were not followed. Specifically, a nurse aide did not wear eye protection when entering the room of a resident diagnosed with influenza, congestive heart failure, and chronic kidney disease. Another nurse aide improperly disposed of a face shield outside the room of a resident with similar diagnoses, contrary to the facility's policy that requires PPE disposal bins to be inside the resident's room. The Director of Nursing acknowledged during an interview that the PPE disposal bin should have been inside the resident's room and that staff should wear PPE appropriately. The facility's failure to adhere to its infection control policy was observed during the delivery of lunch trays to the residents, highlighting lapses in the implementation of droplet precautions. These deficiencies were noted under the regulations 28 Pa Code 201.18(b)(1) Management and 28 Pa Code 211.12(d)(1)(5) Nursing Services.
Plan Of Correction
Preparation and evaluation of the enclosed plan of correction set forth in these documents does not constitute admission or agreement by the provider of the truth of the facts alleged or concluded set forth in the statement of deficiencies. The plan of correction is prepared and or executed solely because it is required by the provision of Federal and State law. F-0880 Infection Prevention and Control 1. Resident #46 - Re-Education provided to the staff member on proper donning of PPE for Droplet precautions by Infection Preventionist. Resident #68 - Re-Education provided to the staff member on proper doffing of PPE for Droplet precautions by Infection Preventionist. 2. All resident rooms on precautions were checked to ensure PPE donning and doffing set up was done per facility policy and staff were following the correct procedures. No other discrepancies found. Donning and Doffing was reviewed with staff by Infection Preventionist on 1/23/25. 3. Policy on Infection Control will be reviewed and revised as necessary by DON. Re-education will be provided to the Healthcare staff on Infection Control and proper donning and doffing of PPE via Relias with education completed by 2/21/25. 4. QA Coordinator will audit for proper donning and doffing of PPE. 5 donning or doffing audits will be done weekly X2 weeks, bi-weekly x2 weeks then monthly x2. Any immediate concern will be brought to DON for immediate attention and re-education. Audits will be reviewed at QA Meetings. All Corrective actions will be completed by 2/25/25.