Failure to Follow Infection Control Protocols and Transmission-Based Precautions
Penalty
Summary
Multiple staff members failed to adhere to infection prevention and control protocols, including hand hygiene (HH), use of personal protective equipment (PPE), and proper medication handling. During meal tray delivery, a staff member was observed touching items in resident rooms, wiping their face, and delivering trays to multiple residents, including one on transmission-based precautions (TBP), without performing HH at any point. Similarly, during a medication pass, a nurse handled medications with bare hands, touched various surfaces, administered medications, and used personal items such as a cell phone, all without performing HH between tasks or after glove removal. The nurse also failed to follow the facility's policy of placing medications directly into cups and not handling them directly. Staff also failed to follow posted TBP signage and PPE requirements for residents on isolation precautions. For example, two staff members entered a room with a posted Contact Precautions sign without donning the required gown and gloves, despite the signage instructing all entrants to do so. Another staff member entered a room requiring Special Droplet/Contact Precautions without wearing the required eye protection. Additional observations showed staff not performing HH before donning gloves, wearing damaged gloves during resident care, and failing to perform HH after glove removal and before exiting isolation rooms. The facility's policies required strict adherence to HH before and after resident contact, after glove removal, and when entering or exiting isolation rooms, as well as the use of appropriate PPE as indicated by posted signage. Staff interviews confirmed that expectations for HH and PPE use were known, but staff did not consistently follow these protocols. These lapses were observed in the care of residents with active infectious diseases who were on TBP, as well as during routine care and medication administration.