Infection Control Deficiencies in PPE Use and Precaution Adherence
Penalty
Summary
The facility failed to implement proper infection control measures in two resident care areas, specifically regarding the use of personal protective equipment (PPE) and handling of potentially contaminated items. In one instance, a Licensed Practical Nurse (LPN) was observed not following the facility's policy on contact precautions while treating a resident diagnosed with influenza and an unstageable pressure injury. The LPN placed treatment supplies on the resident's bedside table and later returned unused gauze to the treatment cart, despite the gauze having been in contact with potentially contaminated surfaces. Another deficiency was observed when an employee failed to adhere to droplet precautions for a resident diagnosed with influenza A. The employee did not perform hand hygiene or wear face protection while entering and exiting the resident's room to serve lunch. This was confirmed by the Nursing Home Administrator, who acknowledged that droplet precautions were not followed during the observation. Additionally, a third incident involved an employee not using PPE or performing hand hygiene while entering the room of a resident on contact precautions for scabies. The employee delivered a meal tray to the resident and continued to serve other residents without following the necessary infection control protocols. The Nursing Home Administrator confirmed that employees are expected to follow facility policies regarding contact precautions.
Plan Of Correction
1. R2 no longer resides at the facility. R5 and R25 continue to reside at the facility. E1, E3, and E7 were educated immediately by the DON and IP Nurse on facility policy review to ensure staff implemented infection control policies to prevent the spread of infection by using PPE (personal protective equipment) and educated on how to handle potentially contaminated items to decrease the possibility for transmission of infectious disease for one of one unit treatment carts observed, along with education on Transmission-based (Isolation) precautions "Contact Precautions" to wear a gown for all interactions that may involve contact with residents or potentially contaminated areas in the residents' room and/or environment. 2. The facility has determined that all residents have the potential to be affected by this deficient practice. 3. A Root Cause Analysis was conducted and the cause was determined that the facility staff member E3 failed to implement infection control policies to prevent the spread of infection by not using PPE (Personal Protective Equipment) in R2 care areas while providing wound care to R2, failed to follow droplet precautions to use gloves, mask, eye protection, and gown. Then E3 was also observed moving an unused, unopened pack of gauze from the bedside table to R2's bed, while observed exiting the room, and returning the pack of gauze into the box in the treatment cart from where they were moved. E7 failed to perform any hand hygiene prior to entering residents R5 and R7 rooms to provide lunch on a tray, then proceeded to assist R5 with assistance of lunch. E7 failed to adhere to the droplet precautions on R5 door that revealed resident was on droplet precautions. E1 failed to enter R25's room while resident was on contact precautions and enter R25's room with lunch tray, set it up for R25 to eat then exit the room and continued on taking trays to other residents, exiting R5 room without wearing any face protection upon entering room, and failed to handle potentially contaminated items to decrease the possibility for transmission of an infectious disease from the Love and Love two units, then to one of one unit treatment carts on the Love unit. 4. A facility-wide audit will be conducted by the DON, IP Nurse, and Shift Supervisors by March 14, 2025, to review all residents who have the potential to be affected by this deficient practice. Re-educate all staff (including maintenance, housekeeping, dietary, administration, etc.) on donning personal protective equipment (PPE) upon room entry and discarding before exiting the room which is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination. The education will also include identifying, reporting, and prevention of the Transmission-Based (Isolation) accepted national standards and how to use disposable or dedicated noncritical resident-care equipment between residents. The following equipment will be cleaned and disinfected by manufacturers' instructions with an EPA-registered disinfectant after use. The DON and IP Nurse will also educate all nursing staff on moving any unused, unopened pack of gauze from the bedside table to another resident's room, as to not exit rooms and returning the pack of gauze into the box in the treatment cart from where they were removed initially, then to and from residents' room without proper droplet precaution awareness of signage. The DON and IP Nurse will continue to re-educate all staff through March 14, 2025, on donning and doffing PPE to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infection. 5. The audit will be conducted by the DON and IP Nurse at the rate of 10% weekly until 100% compliance is achieved for three consecutive audits. Then the audit will be conducted monthly for 3 months. If 100% compliance is achieved/maintained, the deficiency will be considered resolved. Results of the audits will be presented by the DON and IP Nurse and discussed at the monthly QAPI meeting to determine the need for further audits and or action plans.