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F0880
D

Failure to Follow Transmission-Based Precautions for Resident with C. diff

Oregon City, Oregon Survey Completed on 06-06-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Staff failed to consistently follow transmission-based precautions for a resident admitted with Clostridioides difficile (c-diff), who was on enteric precautions. Observations revealed that a CNA entered the resident's room without donning personal protective equipment (PPE) and subsequently exited the room, handled a lunch tray, and accessed common areas without performing hand hygiene. The CNA acknowledged awareness of the resident's precaution status but believed PPE was not required for meal delivery and admitted to not washing hands after leaving the room. Further observations showed another CNA provided care to the resident while wearing gloves but without a gown, and admitted to removing PPE before completing all care tasks. Additionally, the resident was observed ambulating in the hallway during a therapy session without PPE, despite being on transmission-based precautions and expected to remain in their room. Interviews with staff confirmed that education on precautions had been provided and signage was posted, but staff did not consistently adhere to the required protocols.

See complete original report
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