Failure to Ensure Proper PPE Use and Hand Hygiene During Transmission-Based Precautions
Penalty
Summary
Staff failed to ensure proper use of Personal Protective Equipment (PPE) and hand hygiene for residents on Transmission-Based Precautions (TBP). In one instance, a resident with a history of chronic obstructive pulmonary disease and recent testing for COVID-19 was placed on droplet precautions. Observations revealed that staff members entered the resident's room wearing gowns, gloves, and N95 masks, but did not wear required eye protection. One staff member exited the room wearing both an N95 and a surgical mask, walked through the hallway without removing the masks as required, and later returned to the room with a face shield but only a surgical mask. The Director of Nursing confirmed that the facility's protocol required a gown, gloves, N95 mask, and face shield to be worn, with removal of gown and gloves before exiting and removal of the N95 mask immediately upon exit. The resident was not informed about the reason for TBP, and isolation was discontinued after a negative COVID-19 test. Additional observations showed that an LPN did not perform hand hygiene before or after administering medications to residents, including one on contact precautions for COVID-19. The LPN donned a gown and gloves but did not change or remove his surgical mask as required, and failed to perform hand hygiene before donning gloves, contrary to posted recommendations. These actions did not follow the facility's policy and procedures for PPE use and hand hygiene, increasing the risk of cross-contamination.