Infection Control Deficiencies in PPE and Precautionary Measures
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies, resulting in deficiencies in the implementation of Transmission-Based Precautions (TBPs) and Enhanced Barrier Precautions (EBPs) for several residents. Specifically, Resident 12, who tested positive for influenza A, was not properly managed under Droplet Precautions. Observations revealed that an environmental services worker and a registered nurse entered the resident's room without the required personal protective equipment (PPE), such as gowns and eye protection, and the nurse was unaware of the resident's precautionary status due to the absence of appropriate signage. Additionally, the facility did not implement EBPs for residents at risk of Multi-Drug Resistant Organisms (MDROs). Resident 19, with a history of open wounds, and Resident 49, with a suprapubic catheter, were not managed with the necessary protective gowns, and there was no signage indicating their precautionary status. Similar lapses were observed for Resident 86, who had a permanent catheter, and Resident 131, with an indwelling catheter, as staff entered their rooms without the required protective gowns. The Director of Nursing confirmed that the facility's policies for Droplet and Enhanced Barrier Precautions were not being followed by the staff. This lack of adherence to infection control protocols was observed across two of the three nursing units, affecting five of the 28 sampled residents, and highlights a systemic issue in the facility's infection control practices.
Plan Of Correction
1. DON/Admin rounded the facility to ensure all staff were wearing proper PPE. Signage applied to identified rooms. 2. Educated staff on donning and doffing PPE. 3. Full house re-education will be provided to all staff on the proper usage of PPE, infection control, donning and doffing PPE. 4. DON or designee will complete audits weekly x2 to ensure appropriate signs are displayed outside of resident rooms and staff are wearing proper PPE while providing care. Results will be reviewed at QAPI.