F0880

D

Failure to Ensure Staff Use PPE for Residents on Contact Precautions

Saint Petersburg, Florida Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement an effective infection prevention and control program by not ensuring staff consistently donned appropriate PPE when caring for residents on contact precautions. For one resident with loose stools and a physician order for contact isolation due to possible Clostridioides difficile (C. diff), a CNA was observed standing in front of the resident, speaking with them, and then leaving the room without wearing any PPE. A Contact Precautions sign from the CDC was posted on the resident’s door, instructing all providers and staff to clean their hands, don gloves and a gown before room entry, and discard them before room exit, and to use dedicated or disinfected equipment. There was no PPE available at the doorway at the time of the observation.

During an interview shortly after the observation, the CNA stated that the resident did not have any precautions. The LPN confirmed that the facility was attempting to obtain a stool sample for C. diff because the resident had loose stools. Review of the resident’s record showed an active physician order dated two days prior for “Contact Isolation every shift for possible cdiff for 5 days,” and an order to obtain stool for C. diff and ova and parasites for loose stool for three days. The resident’s diagnoses included multiple fractures of ribs on the left side with routine healing, generalized muscle weakness, and unspecified convulsions. Despite the posted CDC-based Contact Precautions sign and the active contact isolation order, the CNA entered and interacted with the resident without required PPE and later acknowledged that PPE was required and confirmed being in the room without it.

A second deficiency event involved another resident with an active physician order for contact isolation every shift for methicillin susceptible Staphylococcus aureus (MSSA) to a wound. An Activity Assistant was observed entering this resident’s room and closing the door without donning any PPE, despite a CDC-based Contact Precautions sign posted on the door that instructed staff to clean their hands before entering and when leaving, don gloves and a gown before room entry, discard them before room exit, and use dedicated or disinfected equipment. No PPE was available in the hallway directly outside the room. The Activity Assistant reported having been educated on transmission-based precautions and PPE use, stated that gloves, mask, gown, and face shield should be worn for contact precautions, and indicated that PPE is used when there are signs on the door. After reading the sign, the staff member noted it included instructions for soap and water hand hygiene. Review of the resident’s record confirmed active orders for contact isolation for MSSA wound infection and enhanced barrier precautions related to IV access and a coude Foley catheter.

Review of facility policies showed that the Infection Prevention and Control Program policy required all staff to follow policies and procedures related to infection prevention and to use PPE according to established facility policy, and that residents with infections or communicable diseases be placed on transmission-based precautions per current CDC guidelines. The Transmission-Based (Isolation) Precautions policy defined contact precautions as measures to prevent transmission of infectious agents spread by direct or indirect contact, and specified that healthcare personnel caring for residents on contact precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident’s environment, donning PPE upon room entry and discarding it before exiting. The policy also identified contact precautions with soap-and-water hand hygiene for C. difficile for the duration of illness. Despite these written policies and CDC-based signage, staff did not consistently don required PPE when entering the rooms of residents on contact precautions, and PPE was not available at the doorway for the observed residents.