F0880

D

Failure to Use Required PPE for COVID-19 Isolation and Enhanced Barrier Precautions for PICC Line

Rockford, Illinois Survey Completed on 11-25-2025

Penalty

No penalty information released

Summary

The deficiency involves failures in implementing required infection prevention and control measures for residents on transmission-based precautions and those requiring Enhanced Barrier Precautions (EBP). One resident with a documented COVID-19 infection was ordered to be on contact and droplet precautions, with signage posted outside the room specifying the need for gowns, gloves, face shields or goggles, and masks, and a bin of PPE available at the doorway. Despite this, a CNA was observed entering the resident’s room without any PPE to turn off the call light, and an occupational therapist later entered the same room without donning a face shield. The infection control nurse confirmed that no staff should enter the COVID-19 isolation room without all required PPE and that eyeglasses alone are not acceptable in place of a face shield.

A second deficiency involved a resident admitted with sepsis and bacteremia who had a PICC line in the left arm for IV antibiotic administration. Although IV antibiotics were completed, the PICC line remained in place, and there was no physician order or documentation placing the resident on EBP related to the indwelling device. The facility’s isolation list did not show the resident on EBP or any isolation precautions, and repeated observations showed the resident in bed with the PICC line in place, but without any EBP signage on or around the door and without an isolation cart or PPE available near the room. The infection preventionist stated that residents with a PICC line or any type of IV access should be on EBP, and the facility’s EBP policy required signage and readily available gowns and gloves for residents with indwelling medical devices.