Failure to Follow Contact Precaution Protocols During Food Service
Penalty
Summary
Staff failed to adhere to the facility's infection prevention and control program, specifically regarding the use of personal protective equipment (PPE) when interacting with residents on contact precautions. Certified Nursing Assistants (CNAs) were observed delivering food trays to multiple residents on contact precautions without donning the required PPE, such as gowns and gloves, prior to entering the rooms. After serving residents on contact precautions, the same staff members proceeded to deliver food trays to residents not on contact precautions, increasing the potential for the development and transmission of communicable diseases and infections. The facility's policy clearly states that PPE must be worn for all interactions that may involve contact with residents or potentially contaminated areas in the environment when contact precautions are in place. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the involved CNAs confirmed that staff were aware of the requirements for PPE use under contact precautions, including the need to put on PPE before entering the room, even for tasks such as passing food trays. The south unit was on lockdown due to five residents exhibiting gastrointestinal symptoms, and all residents were eating in their rooms. Despite this, staff did not consistently follow the established protocols for infection control, as evidenced by their own admissions and the surveyor's direct observations.