Failure to Follow Contact Precautions and Proper PPE Use
Penalty
Summary
Staff failed to follow standard and transmission-based precautions for a resident who was on contact precautions due to an active shingles infection affecting the right eye. The resident had a history of cerebral palsy and an elevated white blood count, and laboratory results confirmed a positive test for varicella zoster virus. Upon return from the hospital, the resident was placed on contact precautions, with a sign posted on the door indicating the need for hand hygiene and the use of gowns and gloves before entering the room. Despite these precautions, observations revealed that a hospitality aide entered the resident's room to deliver a meal tray without performing hand hygiene or donning the required personal protective equipment (PPE) as indicated by the signage. The aide was unaware of the reason for the contact precautions and could not articulate the need for PPE. Additionally, the PPE cart, which should have been placed outside the resident's room for easy access and to prevent contamination, was instead located inside the room, contrary to best practices and the facility's own infection control expectations. Interviews with staff, including a licensed practical nurse, a nursing assistant, the assistant director of nursing (who also served as the infection control nurse), and the director of nursing, confirmed inconsistent understanding and implementation of infection control protocols. Staff acknowledged the resident was on contact precautions and that hand hygiene and PPE use were required, but the PPE cart was not properly positioned, and staff did not consistently follow hand hygiene or PPE protocols. Facility policies outlined the need for standard and transmission-based precautions, but did not specify PPE cart placement, contributing to the observed deficiencies.