Failure to Ensure Proper PPE Use for Resident on Contact Precautions
Penalty
Summary
Staff and a visitor failed to use proper personal protective equipment (PPE) when entering the room of a resident who was on contact precautions due to a wound infection. Despite a sign on the resident's door indicating the need for gowns and gloves, multiple observations showed that both staff members and a family member entered and remained in the room without donning the required PPE. The PPE cabinet near the resident's room did not contain gowns, and there were no other PPE cabinets in the vicinity. Interviews revealed that the family member was not informed about the need for PPE, and staff admitted to not wearing gowns or gloves while providing direct care, such as bed baths, citing oversight as the reason. The Infection Preventionist confirmed that the resident was on contact precautions and that staff should have been using gowns and gloves, but acknowledged that she had not educated the family member about the precautions and only checked PPE supplies weekly. Additionally, there had been no recent staff training on transmission-based precautions, and the Infection Preventionist was unsure how often such education was provided. Facility policy required PPE for anyone entering the room of a resident on isolation precautions, but this was not consistently followed for the resident with a wound infection.