Failure to Follow Contact Precaution Protocols for Infection Control
Penalty
Summary
A Certified Nurse Assistant (CNA) entered a room designated for Contact Precautions without donning the required personal protective equipment (PPE), specifically a gown and gloves, as mandated by the facility's infection control policies. The CNA performed hand hygiene, removed a lunch tray from the food cart, and entered the room, which had a visible Contact Precautions sign, without wearing PPE. Once inside, the CNA donned gloves but did not wear an isolation gown, then proceeded to reposition the resident, place a clothing protector, and open beverages, all while wearing the same pair of gloves and no gown. Upon exiting, the CNA acknowledged that she typically wears a gown and gloves before entering such rooms but could not explain the lapse on this occasion. The resident involved had been admitted with chronic respiratory failure, tracheostomy status, and gastrostomy status, and had been placed on Contact Precautions due to a diagnosis of Candida Auris. Interviews with facility staff, including a Licensed Vocational Nurse and the Infection Practitioner, confirmed that the facility's policy requires staff to perform hand hygiene and don both gown and gloves before entering any Contact Precaution room. Review of the facility's policies and procedures further supported these requirements, and the Operational Manager acknowledged that the CNA did not follow established protocols.