Failure to Follow PPE and Hand Hygiene Protocols for Resident on Contact Precautions
Penalty
Summary
A deficiency occurred when an Advanced Registered Nurse Practitioner (ARNP) failed to follow proper Personal Protective Equipment (PPE) protocols and hand hygiene while providing care to a resident on Special Contact Precautions for Clostridium Difficile (C-diff). The ARNP entered the resident's room without donning appropriate PPE or performing hand hygiene, despite the presence of a PPE cart and multiple precaution signs on the door. During the interaction, the ARNP leaned over the resident's bed, touched the bed with her clothing and items in her hands, and used a clipboard, telephone, and ink pen, which were not disinfected between uses. The ARNP then exited the room without washing her hands and proceeded to visit other residents, again failing to perform hand hygiene or use PPE as required. The ARNP was unaware that the resident was on isolation precautions and misunderstood the meaning of Special Contact Precautions, believing it only meant not to touch the resident. The resident involved had a diagnosis of Enterocolitis due to C-diff and physician orders for contact precautions and specific medication. The facility's infection prevention and control policy required staff education and adherence to proper infection control techniques, which were not followed in this instance. The Infection Control Preventionist acknowledged awareness of the incident and the need for improved education for consultant staff.