Failure to Implement Proper PPE and Isolation Precautions
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed, specifically regarding the use of personal protective equipment (PPE) and staff awareness of isolation precautions. During observations, staff members, including a wound nurse and a CNA, entered a resident's room that was marked for enhanced barrier precautions (EBP) and droplet precautions without wearing masks, although they wore gowns and gloves. The wound nurse was unaware of the reason for the droplet precaution signage and believed the resident was only on contact isolation. The CNA did not question the signage, assuming the resident was no longer in isolation, and indicated she was unaware of any prior droplet isolation for the resident. The resident involved had multiple diagnoses, including neuromyelitis optica, paraplegia, pressure ulcer, neuromuscular dysfunction, dysphagia, and anemia, and was cognitively intact. Physician orders indicated EBP due to wounds and a Foley catheter, and there had been a previous order for contact and droplet precautions related to a COVID-19 infection. The care plan also indicated contact isolation for prophylactic antibiotic use for C. difficile. Despite these orders and signage, staff did not consistently implement appropriate PPE use or verify the current isolation status, leading to a failure in following infection control guidelines.