Failure to Adhere to Infection Control Standards and PPE Use
Penalty
Summary
Staff failed to adhere to infection prevention and control standards, specifically regarding the use of personal protective equipment (PPE) and proper hand hygiene, for three residents under enhanced barrier precautions (EBP) or contact precautions. For one resident with a chronic right foot ulcer and multiple comorbidities, a therapy assistant was observed wearing gloves but not a gown during high-contact care activities, and also wore gloves outside the resident's room, contrary to facility policy. The therapy assistant acknowledged receiving infection prevention training and recognized the error in PPE use and glove handling. Another resident, with a history of recurrent Clostridium difficile infection and other medical conditions, was on contact precautions. Multiple staff members, including a physical therapy aide and nursing assistants, entered the resident's room without donning the required gown and gloves, and failed to perform hand hygiene after leaving the room. Staff interviews revealed awareness of the precautions but lapses in compliance, with some staff citing being in a hurry or believing PPE was unnecessary if the resident was not touched. A third resident, on EBP following joint replacement surgery and with several chronic conditions, received high-contact care from a nursing assistant who wore gloves but not a gown, and was unaware of the specific reason for the precautions. The facility's policies required gowns and gloves for high-contact care in EBP and contact precaution rooms, and mandated hand hygiene after glove removal and before leaving resident rooms. The director of nursing confirmed that staff were expected to follow these protocols and acknowledged the observed lapses.