Failure to Adhere to Infection Control Standards and PPE Use
Penalty
Summary
The facility failed to adhere to infection prevention and control standards for three residents, resulting in deficiencies related to the use of Personal Protective Equipment (PPE) and compliance with established precautions. For one resident with severe cognitive impairment and diagnoses including bacteremia and ESBL, staff did not wear the required gown and gloves while assisting with feeding, despite clear signage indicating contact precautions. The staff member was unaware of the resident's precaution status and did not observe the posted instructions before entering the room. Another resident, who had a tracheostomy and was dependent on staff for care, was placed on both contact and droplet precautions due to pending respiratory infection tests. Multiple staff members, including a CNA and a housekeeper, entered the resident's room without donning any PPE, even though signs were posted and the resident was actively coughing and sneezing. PPE supplies were not positioned at the room entrance, which contributed to staff missing the requirement to use them before entry. For a third resident with a PICC line and orders for Enhanced Barrier Precautions (EBP), a nurse failed to wear a gown while performing high-contact care activities such as flushing the PICC line, despite signage and policy requiring both gown and gloves for such procedures. The nurse believed EBP was only necessary for wound care, not device care, and only wore gloves. The staff development coordinator confirmed that EBP should have been followed for all high-contact care involving the PICC line.