Failure to Use PPE During Contact Precautions
Penalty
Summary
Facility staff failed to follow appropriate infection control practices when a housekeeper was observed mopping the floor in a resident's room that was under Contact Precautions for Vancomycin Resistant Enterococcus (VRE) urinary tract infection. Despite clear signage and the availability of personal protective equipment (PPE) such as gowns and gloves at the room entrance, the housekeeper did not wear any PPE while inside the room. The signage specifically instructed all providers and staff to don gloves and gowns before entering and to discard them before exiting the room. The housekeeper stated that PPE was only required for aides providing direct care, not for housekeeping staff. The resident in question had an active order for special contact isolation precautions due to a VRE UTI, with all services to be provided in the resident's room. The care plan also included an intervention to maintain contact isolation precautions for the duration of antibiotic treatment. Both the Infection Preventionist and the Director of Nursing confirmed during interviews that housekeeping staff should have been wearing PPE in accordance with facility policy and the posted instructions. Facility policy required staff and visitors to wear disposable gowns upon entering rooms under contact isolation and to avoid contaminating surfaces after gown removal.