Failure to Follow PPE Disposal Protocols During Resident Care
Penalty
Summary
A deficiency occurred when a Nurse Manager failed to follow proper infection prevention and control procedures while providing care to a resident with multiple complex medical conditions, including hemiplegia, muscle wasting, cognitive impairment, and a history of cerebral infarction. The Nurse Manager performed direct care involving a PICC line for the resident, who was dependent on staff for activities of daily living and had orders for Enhanced Barrier Precautions (EBP). After completing care, the Nurse Manager exited the resident's room wearing contaminated personal protective equipment (PPE), including a gown and gloves, and removed the PPE in the hallway, disposing of it in a trash can on the medication cart across the hall, rather than in the designated trash can inside the resident's room as required by facility policy. Interviews with staff, including the Nurse Manager, CNA, RN, medication aide, ADON, and Administrator, confirmed that the facility's policy and standard infection control practices require staff to remove and dispose of PPE inside the resident's room and perform hand hygiene before exiting. The Nurse Manager acknowledged not following these procedures and stated a misunderstanding about the disposal requirements. Other staff members consistently described the correct process and the importance of proper PPE use and disposal to prevent the spread of infection. Facility policy specifically directs that a trash can be positioned inside the resident's room for PPE disposal prior to exit.