Failure to Ensure Proper PPE Use for Contact Isolation and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) by both staff and visitors when entering rooms of residents on contact isolation or enhanced barrier precautions. In one instance, a staff member was observed adjusting a resident's brief without wearing a gown, despite signage indicating the need for both gown and gloves for high-contact care activities. The staff member acknowledged the omission and confirmed awareness of the required PPE. The facility's interim Director of Nursing confirmed that not wearing the required PPE could lead to the spread of infection, and the facility's policy specifies the use of gowns and gloves for residents with indwelling medical devices or those at risk for multi-drug-resistant organism (MDRO) transmission. A visitor was observed inside a resident's room on contact isolation for Clostridium difficile without wearing a gown or gloves, despite clear signage and facility policy requiring such precautions. The infection preventionist stated that both staff and visitors should be informed and educated about the necessary PPE, and that the visitor should have been notified and required to wear the appropriate equipment. The facility's guidelines reinforce the use of contact precautions for residents with infections that can be transmitted by direct or indirect contact. Additionally, an agency registered nurse was observed providing care to two residents on enhanced barrier precautions without wearing a gown, despite signage and facility policy. The nurse admitted to not receiving a report about the required precautions and acknowledged the need to wear a gown. The interim Director of Nursing stated that all staff, including agency personnel, are expected to follow facility policy and signage regarding PPE use for residents on enhanced barrier precautions, especially during high-contact care activities.