Failure to Follow Infection Control Policies for Isolation Precautions and PPE Use
Penalty
Summary
The facility failed to adhere to its infection control policies regarding the placement of isolation precaution signs and the use of personal protective equipment (PPE) for residents on contact and enhanced barrier precautions. Multiple instances were observed where required signage was missing or not properly displayed, and staff or visitors entered rooms without donning appropriate PPE as mandated by facility policy. For example, a hospice account executive was seen in a resident's room on contact isolation for E. coli without wearing any PPE, despite clear signage instructing the use of gloves and gowns before entry. In another case, two CNAs provided high-contact care to a resident on enhanced barrier precautions, including dressing and urinary catheter care, without wearing isolation gowns. One CNA admitted uncertainty about the resident's precaution status and the requirements for enhanced barrier precautions. Additionally, a resident with a colostomy, who should have been on enhanced barrier precautions, had no signage at her door for several days, and the infection preventionist acknowledged the oversight, attributing it to the sign being flipped backward. A further deficiency was noted when a resident with a recent room change and an active order for contact isolation due to VRE in the urine had no signage or PPE supplies at the new room entrance. The infection preventionist only brought the necessary sign and PPE bin after being questioned by the surveyor. The facility's own policies require clear signage and the use of PPE for both transmission-based and enhanced barrier precautions, but these protocols were not consistently followed for several residents, as evidenced by direct observation and staff interviews.