Failure to Use Required PPE for Resident on Contact Isolation for C. diff
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed its infection prevention and control program and CDC guidance for contact precautions for a resident on isolation for Clostridioides difficile (C. diff). The facility’s policy titled “Infection Surveillance” (revised 12/2022) stated that infection surveillance is a core activity of the infection prevention and control program, intended to identify infections and monitor adherence to infection prevention practices to reduce and prevent the spread of infections. CDC guidance for Transmission-Based Contact Precautions (dated 4/2024) requires the use of appropriate PPE, including wearing a gown and gloves for all interactions that may involve contact with the resident or the resident’s environment when the resident has an infection that poses increased risk for contact transmission. Resident 3 was admitted on an unspecified date and had physician orders dated 2/18/26 for contact precautions related to C. diff and for hemodialysis access site monitoring for a central catheter in the right upper chest, with dressing changes at the dialysis center and as needed every shift, and monitoring for signs and symptoms of infection. The resident’s H&P dated 2/25/26 documented that the resident had capacity to make medical decisions. On 3/12/26 at 1617, surveyors observed a contact precaution sign and isolation cart outside the resident’s room, while RN 1 was inside the room kneeling at the bedside performing a dressing change on the resident’s dialysis site without wearing a gown. In a subsequent interview, RN 1 confirmed the resident was on contact isolation for C. diff, acknowledged she was not wearing a gown, and stated she should have worn one, noting that contact precautions include donning a gown and gloves. The DON later verified the resident was on contact isolation for C. diff and stated she expected staff to wear gowns and gloves in contact isolation rooms and that proper PPE use ensures infection control is maintained. The Administrator and DON acknowledged the findings during interview.
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