Failure to Use Required PPE for Contact Precautions
Penalty
Summary
The deficiency involves the facility’s failure to consistently implement its infection prevention and control program by not ensuring required PPE use for residents on Contact precautions. A resident admitted with diagnoses including malnutrition and Type 2 Diabetes Mellitus, and with moderately impaired cognition per a recent MDS, had physician orders for Contact transmission-based precautions for diarrhea. On multiple observations, CNAs entered and exited this resident’s room, which had a Contact precautions sign posted on the door, wearing only surgical masks and without donning gowns and gloves. One CNA acknowledged that Contact precautions required a gown and gloves and confirmed that neither she nor another CNA had donned the required PPE. The resident reported that staff did not wear gowns when entering the room and normally only wore gloves. A PPE cart near the resident’s room was observed to be missing gloves, and staff had to retrieve gloves from another resident’s room. Additional observations showed that a laundry aide entered four resident rooms without performing hand hygiene and wearing only a surgical mask, and then entered a room with a Contact precautions sign without donning any additional PPE. The laundry aide stated that she normally just went in and out with clean laundry without using a gown or gloves. The Corporate Infection Control staff member reported that the facility’s expectation was that all staff entering a Contact precautions room don a gown and gloves. The facility’s written Transmission-Based Precautions policy stated that healthcare personnel caring for residents on Contact precautions wear a gown and gloves for interactions that may involve contact with the resident or potentially contaminated areas in the resident’s environment, and that PPE is to be donned upon room entry and discarded before exiting to contain pathogens.
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