Failure to Follow Droplet Precaution PPE Protocols for Residents with Influenza
Penalty
Summary
Facility staff failed to implement infection control precautions in accordance with established policies and procedures for two residents who required droplet precautions due to influenza. Certified Nurse Assistants (CNAs) were observed at the bedsides of both residents wearing only face masks, without donning the required gown, gloves, and face shield, despite clear signage and available personal protective equipment (PPE) outside the rooms. Both CNAs acknowledged during interviews that they were aware of the requirement to wear full PPE when entering rooms under droplet precautions, and admitted they should have been wearing all required PPE while interacting with the residents. Resident 4 had a diagnosis of immunodeficiency and influenza, with care plans and physician orders specifying the need for contact and droplet isolation precautions. Signage outside the resident's room detailed the sequence for donning PPE, including gown, mask or respirator, goggles or face shield, and gloves. Despite these instructions, CNA 1 was observed at the bedside wearing only a face mask. The Infection Preventionist (IP) confirmed that all staff, visitors, and contractors were required to wear full PPE when entering rooms with droplet precautions, regardless of the nature of the interaction. Similarly, Resident 3, who had bronchitis and was also on contact and droplet precautions due to influenza, was observed in her room when CNA 2 entered wearing only a face mask. Resident 3 reported that staff did not always wear a gown and face shield when providing care. The care plan and physician orders for Resident 3 also specified the need for isolation precautions and in-room care. The IP reiterated that full PPE was required for anyone entering the room, as indicated by the posted signage and facility policy. Facility policies reviewed confirmed the necessity of transmission-based precautions, including the use of gloves, gown, and goggles or face shield when there is a risk of exposure to respiratory secretions.