Failure to Use Required PPE During High-Contact Care for Residents on Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow infection prevention and control practices by not wearing gowns when providing high-contact care to three residents who were on Enhanced Barrier Precautions (EBP) due to multidrug-resistant organism (MDRO) colonization or infection. Observations revealed that staff, including a Certified Occupational Therapy Assistant, a Certified Nursing Assistant, and a Restorative Nursing Assistant, wore gloves but did not don gowns while performing activities such as transferring, changing briefs, and providing therapy or bed mobility assistance. These actions were in direct contradiction to posted EBP signage, physician orders, and the facility's own policy, all of which required both gloves and gowns for high-contact care activities for residents on EBP. The first resident involved had a history of MRSA colonization and was cognitively intact. Despite clear medical orders and posted EBP signage, the therapy staff assisting this resident with daily transfers and exercises consistently wore gloves but never a gown. The second resident, who was severely cognitively impaired and had a history of MDRO in the urine, was observed being transferred and having a brief changed by a CNA who also wore gloves but not a gown. The CNA acknowledged awareness of the requirement but did not comply during the observed care. The third resident, with a history of MRSA wound infection and cellulitis, was assisted by a restorative nursing assistant who transferred the resident's legs and provided bed mobility without wearing a gown, despite the resident's EBP status and relevant physician orders. Both the Infection Preventionist and the Director of Nursing confirmed during interviews that staff were expected to wear both gloves and gowns for high-contact activities with residents on EBP, as indicated by facility policy and CDC guidance. The facility's policy specifically listed activities such as transferring, changing briefs, and providing bed mobility as requiring gown and glove use for residents on EBP.
Plan Of Correction
F880 How corrective action will be accomplished for those residents found to have been affected by the deficient practice. The Infection Preventionist (IP) immediately addressed the deficient practices, including in-services and monitoring to ensure that all isolation precautions were being followed. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. The facility audit concluded that no additional employees were affected. What measures will be put into place or what systemic changes will the facility make to ensure deficient practices do not reoccur? Policy Review and Update: The facility's infection prevention and control policies were reviewed and updated to align with current CDC and CMS guidelines. Staff Education: All staff received mandatory re-education on: • Proper donning and doffing of PPE • Hand hygiene protocols • Room entry/exit infection control practices • Use of transmission-based precautions PPE Stations: All isolation rooms were checked to ensure proper PPE supply. Additional wall-mounted PPE stations were installed where needed. Infection Prevention Rounds: The IP will conduct daily infection control rounds on all shifts for 4 weeks, and weekly thereafter for 3 months. How does the facility plan to monitor its performance to make sure solutions are sustained? The IP or designee will conduct random staff observations during all shifts, using a standardized infection control audit tool. A minimum of 10 observations per week will be logged for 12 weeks. Findings will be reported to the QAPI Committee quarterly. Any deficiencies identified during observations will be addressed immediately with on-the-spot correction and re-education. A quarterly Infection Control Self-Assessment will be completed and reviewed during QAPI. Completion Date: May 8, 2025 PPE Stations: All isolation rooms were checked to ensure proper PPE supply. Additional wall-mounted PPE stations were installed where needed. Infection Prevention Rounds: The IP will conduct daily infection control rounds on all shifts for 4 weeks, and weekly thereafter for 3 months. How does the facility plan to monitor its performance to make sure solutions are sustained? The IP or designee will conduct random staff observations during all shifts, using a standardized infection control audit tool. A minimum of 10 observations per week will be logged for 12 weeks. Findings will be reported to the QAPI Committee quarterly. Any deficiencies identified during observations will be addressed immediately with on-the-spot correction and re-education. A quarterly Infection Control Self-Assessment will be completed and reviewed during QAPI. Completion Date: May 8, 2025