Failure to Maintain Infection Control Precautions for Residents on Isolation and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple breaches in transmission-based precautions for two residents. In one instance, a resident with a confirmed diagnosis of COVID-19 was placed on droplet precautions, with appropriate signage and PPE supplies available outside the room. However, a Licensed Practical Nurse (LPN) was observed entering the resident's room without wearing any required personal protective equipment, including a mask, gown, gloves, or eye protection, despite being aware of the resident's COVID-19 status and the need for such precautions. Both the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), who also serves as the infection preventionist, confirmed that proper PPE should have been used in this situation. In another case, a resident with a tracheostomy was under enhanced barrier precautions, as indicated by signage and a PPE cart outside the room. During tracheostomy care, a Registered Nurse (RN) performed hand hygiene initially but then set up care supplies with bare hands and failed to don a gown, as required. The RN removed and replaced gloves multiple times during the procedure without performing hand hygiene between glove changes, only doing so at the end of the care. The RN acknowledged not following proper hand hygiene protocols and not wearing a gown, both of which were required by facility policy for this type of care. Interviews with the ADON confirmed that hand hygiene should have been performed after each glove removal and that enhanced barrier precautions, including the use of gown and gloves, were necessary for tracheostomy care. The facility's own policies, as well as physician orders, outlined these requirements, but staff failed to adhere to them during the observed care activities.