Failure to Don PPE for Resident on Contact Precautions
Penalty
Summary
Staff failed to properly don personal protective equipment (PPE) when entering the room of a resident who was on contact precautions for conjunctivitis. The resident, who was severely cognitively impaired, had physician orders for contact isolation and was being treated with Ofloxacin Ophthalmic Solution for a bacterial eye infection. A sign was posted on the resident's door instructing staff to gown and glove at the door before entry. Despite these instructions, two staff members, a CNA and a Staffing Coordinator/CNA, entered the resident's room and assisted the resident in bed without wearing gloves or gowns. Upon interview, both staff members indicated they believed PPE was only required when performing personal care or handling urine, not for all room entry. Another staff member, an LPN, echoed this misunderstanding, stating PPE was only necessary when treating the specific problem. However, the Chief Nursing Officer clarified that staff were expected to don gloves and gowns at the door prior to entering the room for any resident on contact precautions. This discrepancy in understanding and practice led to the failure to implement proper infection prevention and control measures.