Failure to Follow Infection Control Protocols for Residents on Contact Isolation
Penalty
Summary
Staff failed to follow proper infection prevention and control practices for residents on contact isolation precautions for Candida Auris. Observations revealed that both nursing and housekeeping staff entered rooms of residents under contact isolation without donning required PPE such as gowns and gloves. Staff were also seen touching medical equipment and resident environments without appropriate PPE and then exiting rooms without performing hand hygiene, contrary to facility policy and physician orders. Multiple residents with severe cognitive impairment and total dependence on staff for activities of daily living were affected, as well as a resident with no cognitive impairment. One resident on contact isolation was observed outside of his room in a communal area without wearing the required isolation gown, and staff interviews confirmed that this resident was sometimes allowed to leave his room without proper PPE due to non-compliance. Housekeeping staff also entered and cleaned rooms of residents on contact isolation without PPE and failed to perform hand hygiene after exiting, indicating a lack of adherence to established infection control protocols. Interviews with staff, including LPNs and housekeeping, revealed a lack of understanding or compliance with the requirements for PPE use and hand hygiene when caring for residents on contact precautions. The Director of Nursing and the Administrator confirmed that all staff should follow transmission-based protocols for residents with Candida Auris, including the use of PPE and hand hygiene, but these protocols were not consistently implemented.