Infection Control Deficiencies in PPE Usage and Precaution Adherence
Penalty
Summary
The facility failed to adhere to infection control guidelines, resulting in multiple deficiencies related to the use of Personal Protective Equipment (PPE) and adherence to Enhanced Barrier Precautions (EBP). Specifically, staff did not wear disposable gowns during personal care and wound care for a resident with a pressure ulcer, nor during medication administration for a resident on EBP. Additionally, PPE was not readily accessible for residents on EBP, and contact precautions were not followed per physician orders for another resident. One resident, who was cognitively intact, had a physician order for contact precautions due to an ESBL-positive urine culture. However, the facility did not conduct a repeat urine culture, and the contact precaution order was not discontinued. The Director of Nursing acknowledged the oversight. Another resident with a PEG tube did not have a gown worn by the staff during medication administration, despite the high-contact nature of the activity. The staff member was unaware of the requirement to wear a gown and noted that gowns were not readily available on the floor. Furthermore, a resident with a stage four pressure ulcer did not have an EBP sign, and staff did not wear gowns during personal and wound care. The Wound Care Nurse and a CNA both failed to wear gowns during high-contact activities, citing a lack of instruction or signage indicating the need for such precautions. The facility's failure to provide accessible PPE and ensure staff compliance with infection control protocols posed a risk to residents on EBP and contact precautions.