Failure to Follow Infection Control Procedures for Contact Isolation and Enteral Feeding
Penalty
Summary
A deficiency occurred when an agency Certified Nursing Assistant (CNA) entered the room of a resident who was on contact isolation for ESBL bacteria without donning the required gown and gloves, despite clear signage on the door and a physician's order for contact precautions. The CNA served the resident's lunch and touched the overbed table with bare hands. The CNA later stated she forgot to apply the necessary personal protective equipment (PPE). Review of her education packet showed she had received general infection control and hand hygiene training, but not specific instruction on contact precautions, although instructions were posted on the resident's door. Facility policy required staff to wear a gown and gloves when entering a contact isolation room. A second deficiency was observed when an LPN, while preparing a bolus enteral feeding for another resident, washed her hands and donned gloves, but then touched the bathroom door and sink with gloved hands before proceeding with the feeding without changing gloves. The LPN acknowledged she should have changed gloves after touching the bathroom sink. Facility policy required handwashing and the use of gloves as indicated for feeding procedures. Both incidents demonstrate failures to follow established infection prevention and control procedures as outlined in facility policy.