F0880

D

Failure to Follow Contact Isolation PPE Protocols and Educate Visitors

Dade City, Florida Survey Completed on 02-02-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically related to contact isolation protocols, PPE use, hand hygiene, and visitor notification and education. On 02/02/2026 at 3:33 PM, a room on the 200 hall was observed with a contact isolation sign requiring gloves and a gown prior to entry, but the sign did not indicate whether the precautions applied to the resident in Bed A or Bed B. Two CNAs (Staff A and Staff B) were observed leaving the side of the room housing the resident in Bed B without wearing gloves or gowns after assisting the resident, who was in a wheelchair, and they did not perform hand hygiene upon exiting.

At 3:37 PM, the same CNAs were observed re-entering the same room without donning gloves or gowns before entry. While in the room, they made contact with the curtain divider, the resident’s wheelchair, and the resident’s shoulder, right hand, and wrist, and then left the room and touched a table in the hallway that contained multiple items, again without performing hand hygiene. At 3:40 PM, another room on contact isolation was observed with a sign on the door that also did not specify which resident the precautions applied to. Staff A and Staff B entered this second room without donning gloves or gowns and exited without performing hand hygiene between rooms.

At 3:36 PM, a family member of the resident in the first room’s Bed B reported not having been told anything about the contact isolation sign, not knowing that gloves and a gown were required before entering, and not having been notified or educated on appropriate PPE use. In a subsequent interview at 3:42 PM, Staff A stated that the contact sign on the first room’s door was for Bed B and acknowledged assisting that resident. Staff A asserted that gown and gloves were not needed because only the resident’s hands were touched without gloves and indicated that PPE would be needed only if the resident was being picked up during a transfer, and that PPE should be put on only if contact was made with a resident, not before entering the room. This understanding conflicted with statements from the RN, DON, and Infection Preventionist, as well as the facility’s written Infection Prevention and Control Program policy, which requires staff to follow transmission-based precautions, including donning PPE before entering contact isolation rooms and informing and educating visitors about required precautions.