Inadequate Use of PPE for Resident on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices for a resident on enhanced barrier precautions. The resident, who had a Foley catheter due to obstructive uropathy and a history of urinary tract infections, required staff to wear a mask, gown, and gloves during high-contact care activities to prevent the transmission of multi-drug-resistant organisms. However, during an observation, a Certified Nurse Aide was seen providing care to the resident, including performing a bed bath, emptying a urinary collection bag, and handling soiled linens, while only wearing gloves and not donning the required mask and gown. Interviews with the Certified Nurse Aide, the Infection Control Preventionist, and the Director of Nursing confirmed that the resident was on enhanced barrier precautions and that staff were required to wear the appropriate personal protective equipment. The Certified Nurse Aide admitted to forgetting to wear the gown and mask, which was a deviation from the facility's infection control policy. This oversight was identified during a complaint investigation, highlighting a lapse in adherence to infection prevention protocols.
Plan Of Correction
Plan of Correction: Approved March 6, 2025 Schoellkopf Health Center submits that its policies, systems and procedures related to the resident care and comprehensive quality improvement program for monitoring of resident care are appropriate. Additionally, it is important to make clear that the submission of this Plan of Correction is not to be construed as an admission that the cited deficiencies are accurate or that at the time of the survey Schoellkopf Health Center did not have policies, procedures and systems in place to maintain compliance with federal and state requirements. However, in an effort to enhance the care furnished to our residents, we have improved some of our existing policies, procedures and systems. I.) The following corrective action was accomplished for the deficiency stated: A.) The CNA that provided care to Resident #2 without donning proper PPE was termed from her agency employment contract on (MONTH) 11, 2025 prior to notification of this deficiency. Due to concerns that the administrator and director of nursing were made aware, the facility had already placed her and her agency contract on a “watch status” for performance improvement, which was not accomplished. This appears to be an isolated incident with this particular CNA as she is quoted by state surveyor during interview saying she “forgot.” This CNA was hired through agency on (MONTH) 10, 2024. During her orientation period she passed bathing and incontinence care, including infection control competency. B.) The facility’s policy and procedure to alert staff of transmission-based precautions, including Enhanced Barrier Precautions were followed as evidence by the proper identification and needed PPE was present outside resident’s room. II.) The following corrective actions have been implemented to ensure all CNA staff are aware of proper PPE/hand hygiene/infection prevention control technique during resident bathing and incontinence care, as all residents have the potential to be affected by the same practice. A.) All CNA staff in serviced by the IP/In-service Coordinator on the proper PPE/ hand hygiene/infection prevention technique for residents on EBP. Inservice will address the proper PPE to wear for residents on EBP to promote a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. B.) All CNA staff will have a competency evaluation performed by the IP/In-service Coordinator on proper PPE/hand hygiene/infection prevention technique while performing resident bathing and incontinence care. C.) IP/In-service Coordinator or designee will provide individualized instruction/training with any CNAs who do not pass competency. D.) All resident on Enhanced Barrier Precautions identified. RN Unit Manager or designee will interview appropriate residents on EBP to confirm staffs’ compliance with infection control measures as all residents on EBP have potential to be affected by same practice. III.) The following systemic changes have been implemented to assure continued compliance with regulations. A.) In addition to current competency evaluations that the IP/In-service Coordinator or designee performs, all staff will be required to complete a Relias training titled “Infection Control: Enhanced Barrier Precautions,” and “Basics of Personal Protective Equipment” by (MONTH) 1, 2025 and then on a yearly basis. B.) Administrator and Director of Nursing reviewed policy titled “Infection Prevention” remains appropriate and no changes were made to the policy. C.) IP/In-service Coordinator or designee will audit resident’s care performed by a CNA for a resident on EBP. Will complete 1 audit per week times 4 weeks, then 1 per month times 2 months to ensure compliance with infection control measures/PPE. D.) IP/In-service Coordinator or designee will provide individualized instruction/training with any CNAs who do not pass competency. IV.) The facilities compliance will be monitored utilizing the following QAPI system. A.) IP/In-service Coordinator will track all staff’s compliance with assigned Relias trainings and report results to QAPI committee, which meets quarterly. B.) IP/In-service Coordinator will report audits to the QAPI committee, which meets quarterly. C.) The IP/In-service Coordinator Nurse will be responsible for overall monitoring and evaluation of implemented plans.