Failure to Follow Infection Control Protocols for Contact and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement its infection prevention and control program as required by policy and posted signage. In one instance, the Staff Development Coordinator (SDC) entered the room of a resident on Contact Precautions wearing gloves but did not don a gown, despite clear signage and facility policy requiring a gown to be worn when entering such rooms. While in the room, the SDC assisted the resident in getting comfortable in bed and disposed of a soiled tissue, then removed gloves and performed hand hygiene before leaving. The SDC later acknowledged the error after reviewing the posted precautions. In a separate incident, a nurse entered the room of a resident with a gastrostomy tube and an Enhanced Barrier Precautions (EBP) sign posted, to administer medication via the tube. The nurse performed hand hygiene and wore gloves but did not wear a gown, contrary to facility policy that requires both gown and gloves for high-contact care activities involving indwelling medical devices. The nurse stated she was told by another nurse that a gown was not necessary, but could not recall who provided this information. Both the Quality Improvement Nurse and the Director of Nursing confirmed that a gown should have been worn in this situation.