Failure to Follow PPE and Hand Hygiene Protocols for Residents on Influenza Isolation
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control practices related to PPE use and hand hygiene for residents on contact and droplet isolation for influenza. One resident had active orders for contact and droplet isolation for influenza, with signage posted instructing staff to remove PPE before exiting the room. An LPN entered this resident’s room wearing the required PPE, including an N95 mask, but the N95 was not properly secured because the top loop was not in use and there was no surgical mask over it. After administering medications, the LPN removed only the gown and gloves when exiting the isolation room and did not remove the face shield or N95 mask, despite posted instructions and facility signage stating that the face shield and mask are considered contaminated and should be removed when exiting an isolation room. The same LPN then entered another resident’s room, who was not on isolation, wearing the same face shield and N95 mask that had been used in the isolation room, and administered medications. In a separate incident, another resident with a positive test for Influenza A and on droplet and contact precautions had a door sign instructing staff to perform hand hygiene before entering and exiting, to fully cover eyes, nose, and mouth, to remove face protection before exiting, and to don gloves and gown before entry. During lunch service, an activity aide entered this resident’s room wearing only a mask, without a gown or face shield, and did not perform hand hygiene upon entering or exiting. The aide then delivered a lunch tray to another resident who was not on isolation and did not have influenza. The infection control nurse confirmed the facility was in a flu outbreak and stated that all staff entering the isolation room should wear a mask (preferably N95), face shield, gown, and perform hand hygiene as preventative measures.
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