Failure to Ensure Proper PPE Use and Consistent Infection Control Documentation
Penalty
Summary
Nursing staff failed to consistently don the required Personal Protective Equipment (PPE) when entering rooms under transmission-based precautions for droplet/contact isolation, as observed in multiple instances involving residents with COVID-19 or other infectious conditions. In several cases, staff entered rooms with posted signage indicating the need for gown, N95 mask, eye protection, and gloves, but were observed wearing only a surgical mask or missing other required PPE. Staff interviews confirmed awareness of the PPE requirements but cited reasons such as being in a rush or lack of available equipment for non-compliance. Documentation related to infection control precautions was also found to be inconsistent. For one resident who tested positive for COVID-19, nursing notes alternated between documenting transmission-based precautions and enhanced barrier precautions across different shifts and days, despite a physician's order specifying the type and duration of isolation. This inconsistency in documentation could lead to confusion among staff regarding the appropriate level of precautions to implement. Additionally, there were instances where staff failed to ensure PPE was readily available outside isolation rooms, particularly eye protection, resulting in staff entering rooms without full PPE. Interviews with the Infection Preventionist and Director of Nursing confirmed that facility policy required full PPE for all staff entering rooms under transmission-based precautions, regardless of which resident was being attended to. The facility's own policies and posted signage were not consistently followed, leading to lapses in infection prevention and control practices.