Failure to Follow Infection Control Precautions for Residents on Contact and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to its infection control policies and procedures in two separate instances involving staff members providing care to residents on transmission-based precautions. In the first instance, a medication aide entered the room of a resident who was on contact precautions due to a wound infection, without donning the required personal protective equipment (PPE), specifically gloves and a gown. Despite a clearly posted sign on the resident's door and a stocked PPE cart outside the room, the aide proceeded to take the resident's blood pressure without the necessary protective attire. The aide later stated she was unaware of the resident's contact precaution status and did not notice the sign, although she acknowledged having received infection control training and understanding the requirements for contact precautions. In the second instance, a nurse aide provided high-contact care activities, including changing bed linens, assisting with activities of daily living, and transferring a resident with a surgical wound and a lower leg dressing, who was on Enhanced Barrier Precautions (EBP). The nurse aide wore gloves but failed to wear a gown, as required by the facility's EBP policy for high-contact care activities. A sign indicating the need for gloves and a gown was posted on the resident's door, and PPE supplies were available at the entrance. The nurse aide admitted to not reading the entire EBP sign and believed a gown was only necessary for wound care, not for other high-contact activities, despite having received training on EBP protocols. Both incidents were confirmed through staff interviews, review of facility policies, and direct observation. The residents involved had active wound care needs, with one on antibiotics for a wound infection and the other requiring daily and periodic wound dressings. The failures to follow established infection control protocols occurred despite the presence of clear signage, available PPE, and prior staff training.