Failure to Follow Infection Control and PPE Protocols During Resident Care
Penalty
Summary
The facility failed to adhere to its infection prevention and control policy by not performing appropriate hand hygiene and not donning required personal protective equipment (PPE) before entering and after exiting resident rooms under enhanced barrier precautions (EBP). Multiple staff members, including nurses, nurse practitioners, and a wound care director, were observed entering EBP rooms and providing direct resident care without donning gowns as required. For example, a nurse entered a resident's room, donned only gloves, and performed gastrostomy tube care without a gown. Nurse practitioners conducted a head-to-toe skin assessment on a new admission without wearing gowns, and the wound care director initially entered a resident's room and removed a dressing without any PPE before later donning PPE for wound care. Additionally, an outside laboratory employee entered an EBP resident room to collect a blood specimen, donned only gloves, and did not perform hand hygiene or wear a gown while touching various surfaces and performing the procedure. The infection prevention nurse confirmed that staff are expected to observe signage for required PPE, don gowns for direct care, and perform hand hygiene before and after entering resident rooms. The facility's policy, revised 7/31/24, specifies that gloves and gowns are required for high-contact care activities and that hand hygiene must be performed before and after direct patient contact.