Failure to Follow PPE Protocols for Resident on Transmission-Based Precautions
Penalty
Summary
Staff failed to follow infection prevention and control practices for a resident who was on both contact and droplet precautions due to an unknown respiratory illness. Despite clear signage at the resident's doorway indicating the need for specific personal protective equipment (PPE)—including gown, gloves, mask, and eye protection—two CNAs were observed providing care to the resident using only gloves while transferring the resident with a Hoyer lift. The required PPE was available on a cart below the precaution signs, and the signs themselves outlined the necessary steps for both contact and droplet precautions. During interviews, the CNAs stated they were unaware the resident was still on precautions and acknowledged they should have worn the full required PPE. The Infection Preventionist confirmed that the resident remained on contact and droplet precautions and that staff are expected to read and follow the posted precaution signs. The deficiency was identified through direct observation, document review, and staff interviews, revealing a failure to adhere to established infection control protocols.