Failure to Follow PPE and Hand Hygiene Protocols for C. diff Precautions
Penalty
Summary
The facility failed to ensure proper use of Personal Protective Equipment (PPE) and hand hygiene for a resident on Transmission Based Precautions due to Clostridium difficile (C. diff) infection. The resident was admitted with diagnoses including enterocolitis caused by C. diff and end stage renal disease, and had active physician orders for Contact Precautions. Observations revealed that a Physical Therapy Assistant exited the resident's room after removing gown and gloves but used hand sanitizer instead of washing hands with soap and water, contrary to facility policy and CDC guidelines for C. diff. The assistant acknowledged forgetting the correct procedure during an interview. Additionally, a Certified Nursing Assistant entered the same resident's room without performing hand hygiene or donning required PPE, and assisted the resident directly, resulting in contact between her clothing and the resident and his wheelchair. The CNA did not perform hand hygiene after the interaction. Both staff members reported awareness of the correct procedures for C. diff precautions, including the need for soap and water handwashing and use of gown and gloves, but failed to follow them. Facility policies reviewed confirmed these requirements for staff caring for residents on Contact Precautions for C. diff.