Infection Control Deficiency: Failure to Use PPE
Penalty
Summary
The facility failed to maintain an effective infection control program concerning Transmission Based Precautions for Resident R113. The deficiency was identified during an observation on January 10, 2025, when a Licensed Nurse, Employee E17, was seen cleansing Resident R113's G-tube site without wearing the required personal protective equipment (PPE). This was despite the fact that Resident R113 was on Enhanced Barrier Precautions, as indicated by a guiding description on the door of the resident's room. Resident R113 had a physician's order dated July 11, 2024, to cleanse the G-tube site daily with soap and water during the day shift. The failure to use PPE during this procedure was confirmed with Employee E17 at the time of the observation. Enhanced Barrier Precautions are infection control measures designed to reduce the transmission of novel or Multi-Drug Resistant Organisms, requiring the use of targeted PPE during high-contact activities.
Plan Of Correction
PPE is now worn for high contact activities with R113. All residents who are on Enhanced Barrier precautions have been reviewed by DON/ educator. PPE is available on the unit for all residents who require use during high contact activities. Licensed nurses will be in-serviced by the educator or designee on the importance of wearing PPE for high contact activities with residents who are on Enhanced Barrier Precautions. Staff educators or designee will conduct random audits during resident care weekly times 4 weeks to ensure PPE is being used appropriately. Results will be reported in monthly QAPI.