Failure to Implement Infection Control Precautions and PPE Use
Penalty
Summary
Facility staff failed to follow established infection prevention and control protocols for three residents requiring either Enhanced Barrier Precautions (EBP) or Transmission-Based Precautions (TBP). For one resident with a history of urinary tract infections and colonization with a multidrug-resistant organism (MDRO), staff did not don required personal protective equipment (PPE), specifically gowns, during incontinence care. The resident’s care plan and physician orders specified EBP, but staff were unaware of the precautions, and appropriate signage and PPE were not consistently available in the resident’s area. Interviews with the involved certified nurse aides revealed a lack of knowledge regarding the resident’s EBP status and the need for gowns, and the resident confirmed that staff did not wear gowns during care. Another resident with a urinary tract infection and a Foley catheter had orders and a care plan indicating the need for EBP. However, there was no visual indicator, such as a colored sticker or signage, in the resident’s room to alert staff to the required precautions. Additionally, PPE was not available on the linen carts as outlined in facility policy. The absence of these measures was confirmed by both observation and staff interviews, indicating a failure to implement the facility’s EBP process for this resident. A third resident with an active Acinetobacter infection in the urine and a provider order for contact isolation did not have appropriate TBP signage or PPE available outside the room. Staff, including CNAs and LPNs, entered and exited the room without donning PPE, and there was confusion among staff regarding the type of precautions required. The facility’s policy required signage and PPE availability for residents on TBP, but these were not in place at the time of surveyor observation. The deficiencies were discussed with facility leadership, but no additional information was provided prior to the survey exit.