Failure of Respiratory Staff to Use Required PPE for Contact Isolation
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to failure to follow contact isolation precautions. The facility’s Isolation Precautions policy, revised in 01/2025, required staff to follow contact isolation precautions, including donning fluid-resistant gowns and gloves upon entering the room of residents with known or suspected infections with epidemiologically important microorganisms. The policy defined PPE for contact isolation as a gown and gloves to be worn upon room entry. Resident #62’s electronic medical record dated 02/10/2026 documented that the resident was on contact isolation precautions for Carbapenem-Resistant Enterobacteriaceae (CRE). On observation, signage posted on Resident #62’s door instructed that contact isolation precautions were required and that everyone must put on a gown and gloves before entering the room. Despite this, two respiratory therapists, S7RT and S8RT, were observed entering Resident #62’s room without donning gowns or gloves. In subsequent interviews, both S7RT and S8RT acknowledged that the resident was on contact isolation precautions and that they had entered the room without wearing the required PPE. The charge nurse, DON, and infection preventionist each confirmed that, given the resident’s contact isolation status, the respiratory therapists should have worn a gown and gloves before entering the room.
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