Failure to Follow Infection Control Protocols for PPE and Hand Hygiene
Penalty
Summary
Staff failed to adhere to the facility's infection prevention and control policies regarding the use of personal protective equipment (PPE) and hand hygiene in rooms under transmission-based precautions. In one instance, an LPN entered a resident's room, who was on contact precautions for ESBL in the urine, without donning a gown and without performing hand hygiene before putting on gloves. The LPN touched the resident and her environment, administered insulin, and then left the room with the insulin pen still in her gloved hand. The LPN then accessed the medication cart, removed the needle, and placed the insulin pen back with other residents' medications, removed her gloves, and failed to perform hand hygiene at any point during or after the process. The LPN later acknowledged that she should have worn a gown and performed hand hygiene as required by facility policy. Other staff, including a speech therapist and housekeeping staff, were observed not wearing the required PPE when entering rooms of residents on contact precautions for ESBL and VRE. The speech therapist stated she only wore gloves when seeing a roommate not on isolation and was unaware a gown was required. Housekeeping staff admitted to sometimes only wearing gloves, depending on how rushed they felt, despite being educated on the need for full PPE. The Assistant Director of Nursing confirmed that all staff, including therapy and housekeeping, are required to wear gloves and gowns when entering rooms of residents on contact precautions. Additionally, the Director of Nursing was observed performing wound care on a resident with pressure ulcers and skin impairment without performing hand hygiene between glove changes. The DON removed and replaced gloves multiple times during the procedure without washing or sanitizing hands, contrary to the facility's hand hygiene policy. The DON later confirmed that hand hygiene should have been performed between glove changes.