Failure to Ensure Required PPE Use for Resident on Contact Isolation
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the use of personal protective equipment (PPE) for a resident on contact isolation. On 1/12/26 at 12:51 PM, a housekeeping staff member (V17) was observed cleaning the room of resident R91, whose door displayed a sign indicating "Contact isolation." During this activity, V17 was only wearing gloves and was not wearing a gown as required by the facility’s transmission-based precautions policy for contact isolation. At the same time, a CNA (V19) was in the same room assisting R91 and removing the resident’s dirty laundry, which was placed in a yellow cinch bag rather than an isolation bag. The CNA carried the laundry from the resident’s room to the soiled utility room without wearing any PPE, including gloves or a gown. On 1/13/26 at 1:05 PM, the facility’s infection control preventionist nurse (V18) stated that staff should wear gloves and a gown upon entering the room of a resident on contact isolation. Facility records showed that R91 was on strict contact isolation precautions due to C. diff, with orders indicating that all needs were to be rendered in the room to prevent cross contamination. An isolation list provided by the facility documented that R91 was on contact isolation for C. diff with a start date of 1/10/26 and a potential stop date of 1/20/26. The facility’s transmission-based precautions policy dated 1/1/25 specified that for contact precautions, hand hygiene and gloves upon entry to the room were required, and a gown was required.
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