Inadequate PPE and Hygiene Practices in Facility
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were in place, particularly concerning the use and availability of personal protective equipment (PPE) and hygiene practices. Observations revealed that PPE supply carts outside rooms with isolation signs were often empty, lacking essential items such as gowns, gloves, masks, and eyewear. This deficiency was noted across multiple rooms with various precautionary signs, including contact, enhanced barrier, and droplet precautions. Staff members, including CNAs, housekeepers, and activities assistants, were observed entering these rooms without the appropriate PPE, failing to perform necessary hygiene practices, and not adhering to the required precautions. Interviews with staff members indicated a lack of awareness and adherence to PPE protocols. For instance, a CNA acknowledged knowing the resident was on contact precautions but failed to don gloves or perform hand hygiene before providing care. Similarly, a housekeeper was unaware of the droplet precautions required for a resident's room and did not know where to obtain PPE supplies. An activities assistant also failed to wear the correct PPE and did not sanitize equipment after use, despite being aware of the droplet precautions. The Director of Nursing (DON) confirmed the expectations for PPE use and acknowledged the inconsistency in staff compliance. The DON also noted the presence of different droplet precaution signs with varying instructions, which could lead to confusion among staff. Additionally, improper storage practices were observed, with non-linen items stored on clean linen carts, further compromising infection control measures.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On [date], clean linen cart on 200 unit was removed and cleaned. On [date], central supply personnel replenished supply cart for # with personal protective equipment. On [date], central supply personnel replenished supply cart for # with personal protective equipment. On [date], central supply personnel replenished supply cart for # with personal protective equipment. On [date], central supply personnel replenished supply cart for # with personal protective equipment. On [date], central supply personnel replenished supply cart for # with personal protective equipment. On [date], central supply personnel replenished supply cart for # with personal protective equipment. On [date], central supply personnel replenished supply cart for # with personal protective equipment. On [date], central supply personnel replenished supply cart for # with personal protective equipment. On [date], Employee "A" was immediately re-educated by the Director of Nursing on isolation precautions/proper PPE use and hygiene. On [date], Employee "G" was immediately re-educated by the Director of Nursing on isolation precautions/proper PPE use and hygiene. On [date], Central supply personnel were re-educated by the Director of Nursing on supply cart replenishment. On [date], Employee "B" was immediately re-educated by the Director of Nursing on isolation precautions/proper PPE use and hygiene. On [date], Employee "C" was immediately re-educated by the Director of Nursing on isolation precautions/proper PPE use and hygiene. On [date], staff members were immediately re-educated by the Director of Nursing on isolation precautions/proper PPE use and hygiene. On [date], Visitor education and encouragement for Control/PPE use and proper hygiene posted conspicuously in reception area by Director of Nursing. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: By [date], a quality review was completed by Director of Nursing/designee on Prevention & Control with emphasis on PPE use, PPE availability, and hygiene. Any issues identified were immediately corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: By [date], staff were educated on the components of Prevention & Control with an emphasis on use and availability of personal protective equipment (PPE) and performing hygiene by the Director of Nursing/Designee. Newly hired staff members will be educated on the components of Prevention & Control with an emphasis on use and availability of personal protective equipment (PPE) and performing hygiene by the Director of Nursing/Designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee to conduct random audits of 5 resident rooms with transmission-based precautions 2x a week for 4 weeks, then 1x a week for 4 weeks and then monthly for 1 month to ensure use and availability of personal protective equipment (PPE) and proper hygiene. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.