Failure to Follow Infection Control Protocols for Residents on Precautions
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program for two of seven sampled residents. For one resident on droplet precautions due to upper respiratory symptoms and a positive rhinovirus test, a maintenance/transport employee entered the resident's room and performed tasks without wearing a mask, gloves, or eye protection, despite clear signage indicating the required personal protective equipment (PPE) and the resident's need for droplet precautions. The staff member's lack of appropriate PPE use was confirmed by both direct observation and staff interviews, and the facility's policy required mask, gloves, and eye protection for droplet precautions. In a separate incident, another resident on enhanced barrier precautions (EBP) for multidrug-resistant organism risk received intravenous medication from the Assistant Director of Nursing, who wore gloves but failed to don a gown as required for high-contact resident care activities under the facility's EBP policy. The EBP signage was posted outside the resident's room, and the staff member acknowledged the omission during an interview. The Director of Nursing also confirmed that administering IV medication is considered high-contact care and requires the use of a gown according to facility policy.