Deficient Infection Control Practices and PPE Compliance
Penalty
Summary
Multiple deficiencies were identified in the facility's infection prevention and control practices, specifically related to the use of personal protective equipment (PPE) and appropriate signage for residents requiring transmission-based precautions. For a resident with recent norovirus and Clostridium difficile infections, the posted contact precautions signage did not specify the need for soap and water hand hygiene, which is required for enteric organisms. Staff interviews confirmed that signage should have included these organism-specific instructions, and observations revealed that contract staff entered the resident's room without donning PPE, stating they had not noticed the sign. Another resident with a newly placed PEG tube was ordered to be on Enhanced Barrier Precautions (EBP), but no EBP signage was displayed on the door during multiple observations. Staff were observed providing high-contact care, such as administering medication via the PEG tube, without donning appropriate PPE. Staff interviews confirmed that EBP should have been implemented upon the resident's admission, but this was not consistently followed. A third resident, readmitted with an ESBL-resistant infection, had contact enteric precautions signage posted, instructing staff to gown and glove upon room entry. However, staff were observed entering the room and handling items such as lunch trays without wearing PPE, stating they believed PPE was only necessary when providing direct care. Interviews with staff revealed a lack of understanding regarding the requirement to don PPE upon room entry, as indicated by the posted signage and facility policy.