F0880

E

Failure to Follow Contact Precautions, EBP, and COVID-19 Testing Protocols

Windsor, North Carolina Survey Completed on 01-13-2026

Penalty

No penalty information released

Summary

The deficiency involves multiple failures by staff to follow the facility’s infection prevention and control policies for Contact Precautions and Enhanced Barrier Precautions (EBP), as well as failure to follow CDC guidance and facility policy for COVID-19 testing after exposure. For a resident on Contact Precautions due to a communicable disease, signage on the door instructed all persons to perform hand hygiene and don gloves and a gown before entering, and to remove them and perform hand hygiene upon exit. Despite this, a nurse aide entered the resident’s room without performing hand hygiene or donning a gown or gloves, picked up the resident’s meal tray, exited the room, placed the tray on the cart, and did not perform hand hygiene afterward. The aide later stated she had received infection control and contact precautions training, acknowledged she should have followed the posted instructions, and explained she was in a hurry and did not look for the sign.

The facility also failed to follow its EBP policy for a resident with a chronic wound who was on EBP. The policy and door signage required staff to perform hand hygiene and wear a gown and gloves for high-contact care such as bathing, dressing, and handling linens. An aide was observed in this resident’s room wearing gloves but no gown after providing a bed bath, handling what appeared to be soiled linens. She dropped the linens on the floor at the end of the bed, later picked them up, held them against her body, carried them across the room, and dropped them on the floor near the trash can. While still wearing the same dirty gloves, she put on her personal fleece jacket. The aide stated she did not notice the EBP sign because she was in a hurry, acknowledged she should have worn a gown, and stated that soiled linens should not be placed on the floor but directly into a plastic bag. The ADON/IP and DON confirmed that EBP had been implemented for this resident due to a chronic wound and that the aide had been trained on EBP and safe linen handling.

The report further describes a failure to follow CDC and facility guidance for COVID-19 testing after exposure. CDC guidance and the facility’s COVID-19 policy required testing residents exposed to COVID-19 no earlier than 24 hours after exposure and as soon as possible thereafter, with CDC recommending a series of three tests after close contact. One resident’s roommate tested positive for COVID-19, and the resident later filed a grievance stating he felt he should be tested because of this exposure. He was not tested until several days after the roommate’s positive result, when the grievance was addressed, and the test was negative. The current ADON, who was a floor nurse at the time, stated the resident should have been tested prior to the grievance date according to facility policy. The previous ADON, who was then responsible for infection control, stated she had been told by the previous Administrator that residents were not tested for COVID-19 unless symptomatic, and she acknowledged that in other facilities she had worked, entire halls were tested after a positive case. The current DON, who was not employed at the time, reviewed the timing and stated the previous infection preventionist did not follow the facility’s COVID testing policy, which reflected CDC guidance.

Another deficiency occurred when staff failed to implement EBP requirements during high-contact care for a resident receiving enteral nutrition via gastrostomy tube. The facility’s isolation policy for EBP required the use of gown and gloves for high-contact resident care activities in the resident’s room, including feeding tube care, and specified that signage above the resident’s bed would inform staff of PPE instructions. During an observation of enteral nutrition administration, a nurse entered the resident’s room, which had an EBP sign posted on the exterior of the door, performed hand hygiene, and donned clean gloves but did not don a gown. She then administered nutrition through the gastrostomy tube using a feeding syringe. In a subsequent interview, the nurse stated she forgot to put on a gown and acknowledged she should have worn one. The DON and Administrator both stated they expected a gown to be worn when providing enteral nutrition in a room with EBP signage.