Failure to Implement and Identify Correct Infection Control Precautions
Penalty
Summary
Staff failed to consistently wear appropriate personal protective equipment (PPE) during high-contact care activities for residents on Enhanced Barrier Precautions (EBP) and did not correctly implement or identify the required level of infection control precautions for a resident on Transmission Based Precautions (TBP). For one resident with arthritis, heart failure, hypertension, and unstageable pressure ulcer, staff measured and cared for wounds while wearing gloves but not a gown, despite facility policy requiring both gown and gloves for wound care under EBP. Staff interviews confirmed knowledge of the policy, but the LPN involved did not wear a gown, stating she did not expect drainage from the wound. Another resident with chronic obstructive pulmonary disease, fibromyalgia, and an indwelling urinary catheter required substantial assistance with personal hygiene and had excoriated areas identified as a yeast infection. During personal care and catheter-related activities, one LPN wore only gloves while assisting with intimate care tasks, including repositioning and perineal care, while another LPN wore both gown and gloves. The LPN who did not wear a gown stated she believed it was unnecessary since she was not performing catheter care, despite direct contact with the resident and the presence of open skin areas. For a third resident with chronic obstructive pulmonary disease, diabetes, and an indwelling urinary catheter, the facility failed to clearly identify and implement the correct level of infection control precautions. Although the resident was on TBP for a Vancomycin Resistant Enterococci (VRE) infection, the signage on the door only indicated EBP, and the resident was not listed on the facility's matrix as being on TBP. Staff interviews revealed confusion between EBP and TBP, and some staff were unaware of any residents on contact precautions, despite the resident's status and facility policy requiring contact precautions for VRE.