Failure to Implement and Follow Transmission-Based Precautions and PPE Practices
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow an ongoing infection prevention and control program, specifically related to transmission-based precautions and staff adherence to posted precautions. Facility infection control policies dated 05/01/25 directed staff to follow CDC guidelines, which require clear signage outside rooms indicating the type of precautions and PPE to be used, PPE availability outside resident rooms, access to alcohol-based hand rub in every room, and trash cans positioned inside rooms near exits for PPE disposal. Observations on the 100 hall showed multiple rooms with various precaution signs and PPE caddies, including a “Modified Protection Environment” sign that did not specify the type of precautions or PPE required, and rooms on special contact, droplet, and enhanced barrier precautions. One resident with an indwelling catheter did not have any transmission-based precaution signage or PPE available, despite the infection prevention coordinator later confirming that residents with indwelling catheters should be on Enhanced Barrier Precautions with PPE available. The infection control coordinator was also observed removing a contact plus droplet precaution sign from a PPE caddy, and the infection prevention coordinator acknowledged that an additional contact plus droplet sign should have been visibly posted for a specific room. The deficiency also includes staff not following the precautions that were posted. A CNA entered a room on special contact and droplet precautions without wearing any PPE and confirmed in interview that he knew the room required a gown, N95 respirator, and eye protection or face shield when entering, but he did not use them. An OT was observed exiting a room while still wearing full PPE, walking down the hall, and then re-entering the room with the same PPE, and later confirmed he should not have exited the room before removing PPE and should don new PPE each time he enters. These observations and interviews demonstrate that staff did not consistently adhere to required transmission-based precautions and PPE use as outlined by CDC guidelines and facility policy.
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