Failure to Follow Infection Control Protocols and Equipment Change Procedures
Penalty
Summary
Facility staff failed to consistently follow infection prevention and control measures as outlined in facility policy and procedure. Staff did not don full personal protective equipment (PPE), including gown and gloves, before entering contact isolation rooms for several residents with active or historical multidrug-resistant organism (MDRO) infections. Observations showed that staff entered rooms with posted contact precautions signage without wearing required PPE, and interviews confirmed that staff were aware of the expectations but did not always comply. The infection preventionist and quality assurance staff acknowledged that the entire room should be treated as contact isolation when any resident in the room is on such precautions, and that PPE must be donned prior to entry regardless of the intended activity inside the room. Additionally, the facility did not ensure that enhanced barrier precaution (EBP) signage and PPE supply carts were present and available for residents requiring EBP due to indwelling devices or colonization with MDROs. In one case, a resident with a history of ESBL and MRSA and an indwelling device did not have EBP signage or a PPE cart outside their room, contrary to facility policy and physician orders. The infection preventionist confirmed that EBP should have been initiated upon admission and maintained throughout the resident's stay, with appropriate signage and supplies in place. The facility also failed to follow protocols for changing respiratory equipment, such as oxygen tubing, nebulizer sets, and yankauers, for two residents. Equipment was observed to be dated several weeks prior, indicating it had not been changed weekly as required by physician orders and facility policy. The infection preventionist confirmed that the equipment should have been changed and properly stored to prevent contamination, and that failure to do so could result in preventable infections.