Failure to Implement Isolation Precautions and Clean Shared Equipment
Penalty
Summary
The deficiency involves failures in implementing appropriate infection prevention and control measures, including incorrect isolation precautions, improper use of personal protective equipment (PPE), and lack of cleaning of shared medical equipment. One resident with diagnoses including cholecystitis and urinary tract infection was readmitted after a hospital stay and had a physician’s order dated 3/13/26 for contact isolation due to a Group A streptococcal blood culture, specifying a contact sign outside the room, gown and gloves for high-contact care, and a face shield for tasks with splash or spray risk. However, surveyors observed that this resident’s room displayed an enhanced barrier precautions sign instead of a contact isolation sign, and the DON acknowledged awareness of the contact isolation order while the resident remained on enhanced barrier precautions. Surveyors also observed a contracted phlebotomist wearing a face mask and blue protective gown enter a room posted with an enhanced barrier precautions sign, then exit and approach another resident in a common area and enter another room without changing the gown and mask, contrary to the posted instructions that gowns and gloves must not be worn for care of more than one person. In a separate observation, an RN obtained a reusable blood pressure cuff from the top of a medication cart and used it sequentially on three different residents who were all on enhanced barrier precautions, returning the cuff to the cart after each use without cleaning or disinfecting it before or after use. The facility’s Infection Prevention and Control Program policy stated that cleaning and disinfection policies must address handling of equipment shared among residents, including blood pressure cuffs, and that reusable medical devices must be cleaned and reprocessed appropriately prior to use on another resident.
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