Failure to Follow Contact Precautions and Hand Hygiene Protocols
Penalty
Summary
A Certified Nursing Assistant (CNA) failed to wear the required personal protective equipment (PPE) when entering the room of a resident who was on contact precautions due to diagnoses of Extended Spectrum Beta Lactamase (ESBL) resistance and Vancomycin-Resistant Enterococci (VRE) in the urine. The resident's room had a clearly posted Contact Precautions sign instructing staff to wear a gown and gloves upon entry. During observation, the CNA was seen transferring the resident from bed to wheelchair without wearing a gown and stated she was unaware of the resident's contact precautions status. Additionally, a housekeeping staff member was observed cleaning the same resident's bed without wearing a gown, contrary to facility policy and procedure for contact isolation. In a separate incident, a Licensed Vocational Nurse (LVN) did not perform hand hygiene after removing used gloves during suprapubic catheter care for another resident. The LVN cleaned the catheter insertion site, removed gloves, and donned new gloves without washing hands in between, despite facility policy requiring hand hygiene after glove removal. The LVN acknowledged the lapse during interview, and the Infection Control Preventionist confirmed that the facility's policy was not followed.