Failure to Follow Contact Isolation Protocols and Proper PPE Use
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment to prevent the development and transmission of communicable diseases and infections for a resident on Transmission-Based Precautions. The facility's policy required all staff to use personal protective equipment (PPE) such as gowns and gloves when entering rooms under Contact Isolation, specifically for residents with Clostridium Difficile. However, multiple observations revealed that staff did not consistently follow these protocols. One certified nurse assistant (CNA) entered the resident's room without donning a gown and gloves, and on another occasion, donned a gown but not gloves while delivering food items. Another CNA was observed removing a food tray from the isolation room without any PPE and placing it on a cart in the hallway, which was later pushed into the dining room without distinguishing the isolation tray from others. Interviews with the infection preventionist and the director of nursing confirmed that staff should wear both gowns and gloves when entering Contact Isolation rooms and that the facility did not use disposable trays for residents on isolation, contrary to best practices. The resident involved was a new admission with diagnoses including cerebral infarction, diabetes, and Clostridium Difficile, and was under a physician's order for Contact Isolation. The failure to adhere to established infection control protocols and improper handling of food trays for a resident on Contact Isolation led to the cited deficiency.