Failure to Adhere to Infection Control Precautions for Residents on Contact and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain proper infection control practices for two residents who required either Contact Precautions or Enhanced Barrier Precautions. In one instance, a certified nurse assistant entered a resident's room with gloves but without a gown, despite signage indicating both were required, and then exited the room carrying a meal tray. The same resident's room was later entered by a licensed practical nurse and another certified nurse assistant without any gloves or gown, and a housekeeper was observed mopping in the room without a gown, even though the posted sign specified the need for both gloves and gown. All staff acknowledged the signage and the requirements but did not adhere to them, despite the availability of personal protective equipment (PPE) outside the room. For another resident on Enhanced Barrier Precautions, staff were observed providing care without the required PPE. One certified nurse assistant was at the room threshold with gloves but no gown, and another was inside the room without gloves or gown, both having removed their PPE after care activities but before leaving the room. Staff expressed confusion about when and where PPE should be worn or removed, particularly during resident transport. The infection prevention nurse confirmed that staff were educated on infection control and that the expectation was for staff to follow the posted signage, which was specific to each resident's needs. Facility policy required clear signage and periodic monitoring of infection control procedures.