Failure to Follow Contact Isolation PPE Protocols
Penalty
Summary
Certified Nursing Assistant (CNA) 1 failed to follow proper infection control protocols when entering the room of a resident who was on contact isolation precautions due to an extended spectrum beta lactamase (ESBL) infection in a right foot wound. Despite clear signage and the presence of a PPE cart with gowns and gloves outside the resident's room, CNA 1 entered without donning the required personal protective equipment to respond to the resident's call light. The facility's policy, as well as CDC guidelines, required staff to wear gloves and a gown before entering rooms under contact precautions. Interviews with CNA 1, the Infection Preventionist, and the Director of Nursing confirmed that CNA 1 was aware of the resident's isolation status and acknowledged the importance of wearing PPE to prevent the spread of infection. Record review indicated that the resident had moderate cognitive impairment and was under strict single room isolation with contact precautions. The facility's policy, dated September 2022, specifically instructed staff to wear gloves and a disposable gown upon entering rooms under contact precautions, which was not followed in this instance.