Failure to Follow Infection Control Policies for PPE and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to follow its infection control policy for two residents, resulting in deficiencies related to the use of enhanced barrier precautions (EBP) and proper disposal of personal protective equipment (PPE). For one resident with a wound infection and a peripheral inserted central catheter (PICC) for antibiotic administration, a Certified Nurse Assistant (CNA) provided high-contact care, including grooming, changing clothes, and repositioning, without wearing a gown as required by EBP protocols. The resident's care plan and signage at the room indicated the need for EBP, and both the CNA and facility leadership acknowledged that PPE, including gowns, should have been used during such care activities to prevent the spread of infection and multidrug-resistant organisms (MDROs). In a separate incident, a used glove was found placed on top of another resident's blanket while the resident was in bed. The glove was observed to be inside out, indicating it had been used, and staff confirmed that used gloves should be disposed of in the trash bin. Facility policy requires that gloves be discarded after a single use to prevent the transmission of infectious material. Interviews with the Infection Preventionist Nurse (IPN) and Director of Nursing (DON) confirmed that both the failure to use appropriate PPE during high-contact care and the improper disposal of used gloves were contrary to facility policies and posed a risk for the transmission of infections. The facility's written policies on EBP and PPE use were reviewed and clearly outlined the requirements that were not followed in these instances.