Failure to Use Required PPE for Residents on Contact Isolation for C. diff
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate infection prevention and control practices, specifically contact precautions and PPE use, for two residents placed under contact isolation for Clostridium difficile (C. diff). One resident, admitted in May 2025 with diagnoses including diabetes mellitus and sepsis, had an active order for contact isolation for C. diff requiring staff to don gown and gloves prior to room entry and care. The roommate, admitted in January 2026 with diabetes mellitus and colostomy status, had a care plan indicating potential for C. diff infection and the need to use infection control principles and contact precautions as indicated. A sign posted at the room door instructed staff to apply gown and gloves before entering. Surveyors observed multiple staff entering and providing care in this isolation room without required PPE. A CNA entered the room without gown or gloves to deliver and set up a breakfast tray for the resident on contact isolation and, at the resident’s request, pulled the light cord with bare hands, later confirming he had touched room surfaces and was unsure which resident the isolation applied to. Two other CNAs entered the same room without gowns to reposition the exposed roommate’s bed and stated they believed gowns were only needed for close contact care involving the urinary catheter. A licensed nurse entered the room without a gown to administer two injectable medications to the resident on contact isolation, during which her clothing contacted the bed and linens; she later confirmed she knew the resident was on contact isolation for C. diff and that she should have used gown and gloves. The DON confirmed both roommates were considered under contact isolation precautions and that all staff entering and providing care to either resident were expected to use gowns and gloves, consistent with the facility’s PPE policy that PPE type is based on transmission-based precautions.
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