Failure to Ensure Proper PPE Use During Resident Care Activities
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by two separate incidents involving staff not following established protocols for personal protective equipment (PPE) use. In the first incident, a Licensed Practical Nurse (LPN) administered an insulin injection to a resident with diagnoses including Type 2 Diabetes mellitus, cerebral infarction, and chronic obstructive pulmonary disease, without donning gloves prior to the procedure. The LPN acknowledged during an interview that gloves should have been worn during the injection. In the second incident, a Certified Nursing Assistant (CNA) provided a bed bath to a resident who was on Enhanced Barrier Precautions (EBP) due to colonization with an extended-spectrum beta-lactamase (ESBL) producing organism, as indicated by a posted sign and the resident's care plan. The CNA did not wear a gown during this high-contact activity, despite being aware of the EBP requirements. The Assistant Director of Nursing/Infection Preventionist confirmed that both gown and gloves are required for such care activities under EBP protocols.