Failure to Provide PPE and Implement Isolation Precautions for Residents on Contact and Enhanced Barrier Precautions
Penalty
Summary
Surveyors observed that the facility failed to ensure appropriate implementation of infection prevention and control measures for residents requiring isolation precautions. Multiple observations revealed that personal protective equipment (PPE) was not available outside or near the rooms of residents on Contact Precautions or Enhanced Barrier Precautions (EBP). Staff were seen entering rooms with posted precaution signs without donning PPE, and PPE storage was inconsistent, with mesh bags inside rooms often found empty. Signs indicating the need for EBP or Contact Precautions were posted, but the required PPE was not accessible as per facility policy and CDC guidelines. Residents involved had significant medical histories, including bacteremia, MRSA, ESBL infections, wounds, and intravenous access, all of which necessitate strict adherence to isolation protocols. Orders and care plans for these residents specified the need for EBP and Contact Precautions, yet observations showed that these precautions were not consistently followed. Staff interviews revealed confusion regarding which residents required which type of precautions, and there was a lack of clarity about the correct placement and availability of PPE. Some staff were unaware of the specific organisms present or the correct isolation status of residents, leading to further lapses in infection control. The facility's own policy required gloves and gowns to be donned before entering rooms under Contact Precautions, and for PPE to be available for EBP during high-contact activities. However, surveyors found that in at least five rooms with posted precaution signs, PPE was not supplied as required. Interviews with the infection preventionist, DON, and other staff confirmed inconsistencies in the application of precautions and the stocking of PPE. The lack of PPE availability and staff adherence to protocols directly contributed to the deficiency in the facility's infection prevention and control program.