Failure to Follow Infection Control Precautions and PPE Use
Penalty
Summary
Staff failed to implement and follow infection control precautions for three residents who required specific infection prevention measures. Facility policy required the use of Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling medical devices, including the use of gloves and gowns during high-contact care activities. One resident with an indwelling urinary catheter and a sacral pressure injury had a care plan intervention for EBP, but a Certified Nurse Aide (CNA) was observed providing bed mobility and adjusting linens without wearing a gown, stating she believed gowns were only necessary during wound care. Another resident with MRSA and an indwelling urinary catheter was under Contact Precautions per physician orders and facility policy, which required staff to wear gloves and gowns upon entering the room. However, a CNA was observed assisting the resident with eating without wearing a gown and stated she was unaware of the specific precautions required for the resident. The signage indicating the need for Contact Precautions was present outside the room. A third resident, who had pancytopenia, a colostomy, and endocarditis, required Neutropenic Precautions, including hand hygiene, gloves, and gowns before entering the room. A CNA entered the resident's room without gloves or a gown, later returning to apply gloves but not a gown, and admitted to forgetting the required PPE. The Director of Nurses confirmed that each resident was on different infection control precautions and expected staff to follow the posted signage and wear the appropriate PPE.