Failure to Follow PPE and Hand Hygiene Requirements for Residents on Contact Precautions
Penalty
Summary
The deficiency involves multiple failures by staff to follow the facility’s infection prevention and control policies, including contact precautions and hand hygiene, for two residents on contact precautions. Resident 1’s admission record showed admission with diagnoses including Type 2 diabetes mellitus with hyperglycemia and gastrostomy status, and a physician’s order placed the resident on contact precautions. Facility signage outside the room directed everyone to clean their hands before entering and when leaving, and directed staff to don gloves and gowns before room entry and discard them before room exit. Despite this, a housekeeper entered Resident 1’s room without any PPE, cleaned and emptied the bathroom and trash bins, then exited the room and did not perform hand hygiene. The housekeeper stated she knew PPE was required when cleaning Resident 1’s room but reported there was no PPE supply available that morning on the rack. Further noncompliance with infection control measures occurred when an RN provided direct care to Resident 1 without PPE and without performing hand hygiene. Resident 1’s physician orders confirmed contact precautions, and the facility’s hand hygiene policy required hand hygiene after contact with blood, body fluids, contaminated surfaces, after touching a resident, after touching the resident’s environment, and immediately after glove removal. During observation and interview, the RN was seen in Resident 1’s room without PPE, then exited without hand hygiene. The RN acknowledged that PPE was supposed to be worn because the resident was on contact precautions and explained that the PPE rack on the door was empty and PPE was stored at the nurse’s station. The RN confirmed having direct contact with Resident 1 by administering medication via G-tube, checking blood sugar, and giving insulin, and acknowledged not performing hand hygiene after this direct care and that this created an increased risk of transmission of infection. Resident 2’s records showed admission with tracheostomy status, gastrostomy status, and ventilator-associated pneumonia, and a physician’s order and care plan placed the resident on contact precautions. The care plan required staff to perform handwashing after completing care and leaving the room and to use PPE. During observation, a CNA was seen at Resident 2’s bedside emptying a urinary drainage bag while wearing a gown and gloves. The CNA then exited the room, removed and discarded the gown in a trash bin located in the hallway outside the room, but did not remove the soiled gloves. The CNA walked toward the nurse’s station while removing the gloves and touched a clean pack of gowns at the station. The CNA stated he removed the gown in the hallway because the garbage bin was outside the room and admitted he did not perform hand hygiene after emptying the urinary bag because he did not think about it. The CNA also reported that the PPE rack on Resident 2’s door was empty and that he had to obtain PPE from the nurse’s station. The facility’s hand hygiene policy and posted "Your 5 Moments for Hand Hygiene" signage required hand hygiene immediately after exposure risk to body fluids, after touching a patient or their surroundings, and immediately after glove removal, which was not followed in this instance.
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