Noncompliance with Infection Control Precautions and PPE Use
Penalty
Summary
Staff failed to comply with infection prevention and control guidelines for multiple residents requiring different levels of precautions. For a resident with an indwelling Foley catheter on Enhanced Barrier Precautions (EBP), a nursing assistant emptied the catheter bag while wearing only gloves and not a gown, despite facility policy requiring both gown and gloves for high-contact activities involving indwelling devices. The staff member stated they did not believe a gown was necessary for this task, even though the EBP signage indicated otherwise. During personal care for another resident with hemiplegia and hemiparesis, a nursing assistant did not change gloves after providing pericare and continued to assist the resident with dressing and handling the resident's wheelchair with the same soiled gloves. The staff member later acknowledged that the gloves were dirty and should have been changed after pericare, but stated they typically only change gloves when visibly soiled. For a resident under investigation for Clostridium difficile (C. Diff), the room was posted with EBP signage instead of the required Contact Enteric precautions. Staff followed the posted EBP instructions, which did not require gown and glove use for all room entry or soap and water hand hygiene, as would be necessary for C. Diff. The error in signage led to staff not following the appropriate level of precautions until the signage was corrected.