Failure to Follow Infection Control Precautions and PPE Use
Penalty
Summary
The facility failed to ensure proper infection control practices for three residents by not adhering to Transmission-Based Precautions (TBP), Enhanced Barrier Precautions (EBP), and appropriate use of Personal Protective Equipment (PPE) during direct care. For one resident with a recent diagnosis of a left thigh fracture and multiple episodes of loose stools, a physician ordered contact isolation to rule out Clostridium difficile (C. diff) infection. Despite this, the resident was observed multiple times in the hallway outside of their private room while still pending lab results for C. diff, contrary to the facility's TBP policy that requires residents on isolation to remain in their rooms except for medically necessary care. Another resident with end-stage kidney disease requiring dialysis and a central line was placed on EBP per physician order, with care plans specifying the use of gown and gloves during high-contact care activities. However, after the resident changed rooms, EBP signage was not posted on the new room door as required, potentially leading to lapses in staff adherence to EBP protocols. Observations confirmed the absence of EBP signage on the door during multiple checks. A third resident, who was treated for a multi-drug resistant organism (MDRO) of the urine and had an open wound, was on contact precautions followed by EBP. During direct care, a CNA was observed providing personal care and changing an adult brief while wearing gloves but not donning a gown, both when the resident was on contact precautions and later on EBP. The CNA was unfamiliar with the meaning of EBP, contact precautions, and the facility's system for identifying residents on precautions, as confirmed during interviews. The Infection Preventionist acknowledged that a gown should have been worn during these care activities.