Failure to Follow Infection Control Protocols for Residents on Precautions
Penalty
Summary
The facility failed to follow proper infection control protocols for two residents with complex medical needs. One resident with multiple pressure ulcers, including a Stage 4 sacral ulcer, was placed on Enhanced Barrier Precautions (EBP) as indicated by signage outside the room. However, staff were observed entering the room and providing direct care while wearing gloves only, without donning the required gowns. Staff confirmed a lack of understanding regarding the need for gowns and noted the absence of gown supplies near the precaution signage, despite the care plan and CDC guidance requiring both gown and glove use for residents with wounds. Another resident with a tracheostomy, MRSA infection, and pneumonia was on droplet and enhanced standard precautions, as indicated by signage and the care plan. Multiple staff members, including LPNs and agency staff, were observed entering the resident's room without wearing masks or eye protection, and in some cases, without performing hand hygiene. Staff interviews revealed a lack of awareness of the required precautions and inconsistent use of personal protective equipment (PPE), even after being reminded of the protocols. The facility's infection preventionist and director of nursing confirmed that staff were expected to use appropriate PPE and educate visitors, but acknowledged that staff compliance was lacking.