Failure to Adhere to Droplet Precaution Protocols for Resident on Isolation
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff not adhering to droplet precaution protocols for a resident who was under isolation. The resident, who had a recent history of respiratory symptoms including cough, nasal congestion, fever, and was being treated for pneumonia and pleural effusion, had a droplet precaution sign posted on the door. The sign instructed all individuals to perform hand hygiene upon entering and exiting the room and to wear a mask when entering. Despite these clear instructions, a Certified Nursing Assistant (CNA) was observed entering the resident's room on two separate occasions without wearing a mask or performing hand hygiene. Interviews with various staff members, including LPNs, CNAs, a Med Tech, the DON, and the Nursing Home Administrator, revealed inconsistent understanding and application of droplet precaution protocols. Some staff believed that precautions were only necessary when providing direct care, while others stated that PPE and hand hygiene were required every time anyone entered the room. The Nursing Home Administrator acknowledged that extra staff, including managers, may have entered the room without following the required precautions, especially during meal delivery. The administrator also noted confusion among staff due to the frequency and variety of precaution signs, which may have contributed to the failure to consistently implement infection control measures as outlined in the facility's policy.