Failure to Use Required PPE for Resident on Contact and Droplet Precautions
Penalty
Summary
The deficiency involves a failure to follow the facility’s infection prevention and control program and PPE policies for a resident on transmission-based precautions. The resident had multiple medical diagnoses, including cerebral infarction with aphasia and hemiplegia, dysphagia, asthma, heart disease, obesity, bipolar disorder, depression, and the presence of a prosthetic heart valve, and had a BIMS score of 03 indicating severe cognitive impairment. The electronic medical record showed the resident tested positive for SARS CoV-2 (COVID-19) and had a physician order for droplet precautions. Signage posted outside the resident’s room indicated both contact and droplet precautions were in place, requiring hand hygiene before entering and upon exiting, donning gloves and a gown prior to room entry, discarding gloves and gown before exiting, using dedicated or properly disinfected equipment, and ensuring eyes, nose, and mouth were fully covered with appropriate face protection prior to room entry and removed before exiting. Despite these posted requirements and facility policies, an LPN was observed entering the resident’s room to obtain vital signs and administer medications while wearing only a surgical mask and gloves, without a gown or eye protection as required by the contact and droplet precaution signage. During interview, the LPN confirmed she provided care without the appropriate PPE and stated she did not believe PPE was required while providing care to this resident, even though she acknowledged the presence of the contact and droplet precaution signage outside the room. The facility’s written Infection Prevention and Control Program policy required residents with infections or communicable diseases to be placed on transmission-based precautions in accordance with CDC guidelines, and the PPE policy required appropriate use of PPE to prevent transmission of pathogens to residents, visitors, and staff. The observed actions and statements of the LPN demonstrated noncompliance with these established precautions and policies.
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