Infection Control Breach by Staff
Penalty
Summary
Elizabethtown Nursing and Rehabilitation was found to be non-compliant with infection prevention and control requirements as outlined in 42 CFR Part 483.80. During an abbreviated survey, it was observed that the facility failed to maintain an effective infection prevention and control program. Specifically, a Physical Therapist, identified as Employee 4, was seen providing direct care to two residents who were under droplet precautions due to COVID-19 without wearing the required personal protective equipment (PPE). This included the absence of an N95 mask, face shield or goggles, gloves, and gown, which were mandated by the facility's updated COVID-19 infection control protocols. The deficiency was further confirmed through interviews with the Director of Nursing (DON), Nursing Home Administrator (NHA), and the Registered Nurse/Infection Preventionist. They acknowledged that Employee 4 had been educated on the facility's COVID-19 policy and procedures but neglected to adhere to them while providing care to the residents. The facility's policy required staff to don specific PPE when entering rooms of residents with COVID-19 exposure or positive tests, which was not followed in this instance, leading to a breach in infection control protocols.
Plan Of Correction
1. Residents 1 and 2 no longer on droplet precautions for Covid 19. Physical Therapist (employee 4) was educated after being identified as not donning proper PPE to enter resident 1 and 2's room and providing therapy services and expressed understanding of why it was important to follow isolation precautions including use of proper PPE when providing treatment for any residents on isolation. Employee 4 donned proper PPE for the remainder of their shift when entering any rooms designated as isolation rooms and providing therapy services. 2. Director of Nursing/designee will conduct a facility wide audit of current residents on isolation precautions to ensure staff are following infection control guidelines including proper donning of PPE prior to entering these identified rooms and for the care of residents on isolation. 3. Director of Nursing/designee will educate facility staff including therapy service staff on Ftag 880 and the importance of following infection control guidelines including donning PPE prior to entering isolation rooms and for care of residents on isolation precautions. 4. Director of Nursing/designee will conduct a random sample audit of 5 residents on isolation precautions to ensure staff are following infection control guidelines including donning appropriate PPE prior to entering isolation rooms and for the care of residents on isolation precautions. These audits will be conducted weekly for 4 weeks and monthly for two months. Results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee for recommendations.