Failure to Ensure Staff Competency in Infection Control and Contact Precautions
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets to prevent the transmission of communicable diseases and infections, specifically regarding contact precautions for a resident with an ESBL infection in the urine. Surveyor observations revealed that a nursing assistant entered the resident's room multiple times without performing hand hygiene or donning required personal protective equipment (PPE) such as gowns and gloves, despite clear signage indicating the need for contact precautions. The nursing assistant also entered another resident's room without performing hand hygiene in between. During interviews, the nursing assistant stated she was unaware of the contact precautions and misunderstood the requirements, believing PPE was only necessary when directly touching the resident. Further interviews with a certified medication technician and an LPN revealed similar gaps in knowledge, with both staff members unable to correctly describe when PPE should be used for residents on contact precautions. The Assistant Director of Nursing Services and Infection Preventionist confirmed that these staff members had completed infection control competencies but could not provide evidence that they demonstrated the necessary knowledge or skills for caring for residents on contact precautions. The deficiency was identified for three out of four nursing staff interviewed regarding contact precautions.