Failure to Provide Dedicated Equipment and Maintain Infection Control for Resident on Isolation
Penalty
Summary
Staff failed to maintain proper infection control practices and did not provide dedicated equipment for a resident on droplet isolation due to streptococcal pharyngitis. The resident, who was cognitively intact but dependent for bed mobility, was placed on droplet precautions per physician orders, with instructions for all care and activities to occur in the resident's room. Facility records indicated that 19 residents were on some form of isolation, and these residents were located throughout the facility. Observations and interviews revealed that staff, including LPNs, used their own personal equipment such as blood pressure cuffs, stethoscopes, thermometers, and pulse oximeters for resident assessments, as the facility did not provide these items. During a vital sign assessment for the resident on isolation, an LPN used personal equipment without cleaning it prior to use, placed the used equipment on top of an isolation cart containing PPE supplies, and performed inadequate cleaning of the equipment after use. The LPN did not allow for the required disinfectant contact time and did not perform hand hygiene after removing PPE or before leaving the resident's room. Interviews with the DON, infection preventionist, and other staff confirmed that the facility did not supply dedicated or disposable equipment for residents on isolation, and that staff routinely used personal equipment. Facility policy required the use of disposable or dedicated equipment for residents on transmission-based precautions and specified proper cleaning and hand hygiene procedures, which were not followed in practice.