Failure to Implement Transmission-Based Precautions and Proper PPE Use
Penalty
Summary
Facility staff failed to implement proper transmission-based precautions on two of four nursing units, specifically the fourth and fifth floors. Multiple staff members, including nursing students and a certified nursing assistant, entered rooms of residents on enhanced barrier or contact precautions without wearing required personal protective equipment (PPE) such as isolation gowns, despite clear signage and available supplies. In one instance, two staff members assisted a resident with a g-tube and tracheostomy while only wearing masks and gloves, contrary to the posted instructions and physician orders. Another staff member adjusted bed linens for a resident with ESBL in the urine while not wearing an isolation gown, and later exited the room carrying soiled items without removing PPE or performing hand hygiene. Additional deficiencies were observed in medication administration and PPE use. A nurse was seen handling medications with bare hands, and another administered eye drops in the hallway, removed gloves without performing hand hygiene, and then touched shared equipment and medication cards before using hand sanitizer. A respiratory therapist was observed leaving a resident's room in full PPE, accessing a supply cart in the hallway with gloved hands, and then re-entering the room, which was inconsistent with facility policy and infection control practices. Interviews with staff and the Director of Nursing confirmed a lack of adherence to established policies regarding PPE use for enhanced barrier and contact precautions. Staff demonstrated confusion or lack of awareness about the requirements indicated on precaution signage, and the DON acknowledged that proper procedures were not followed in the observed situations. Facility policies reviewed required the use of gowns and gloves for high-contact care activities and specified the need for PPE and hand hygiene to prevent the spread of infection, but these were not consistently implemented.