Failure to Follow Contact Precautions During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own infection control policy and procedures for Contact Precautions when a nurse aide did not wear all required personal protective equipment (PPE) while providing incontinence care. The facility’s Contact Precautions policy, revised in October 2018, required staff and visitors to wear clean, non-sterile gloves and a disposable gown upon entering the room of a resident on Contact Precautions, to change gloves after contact with infective material, and to remove gloves and gown with hand hygiene before leaving the room. On the date of survey, a Contact Precaution sign was posted on the door of a resident’s room, with PPE available next to the sign, and the sign specified that all healthcare personnel must wear gloves and a gown when entering the room and remove them before leaving. Surveyors observed a nurse aide completing incontinence care for this resident while wearing gloves but without a gown, despite the resident being on Contact Precautions for an ESBL (Extended Spectrum Beta-Lactamase) urinary infection. In an interview immediately after the observation, the nurse aide acknowledged awareness that the resident was on Contact Precautions, confirmed she had just completed incontinence care, and stated she was moving fast and forgot to put on a gown. The ADON/Infection Preventionist, DON, the assigned nurse, and the Administrator each confirmed in separate interviews that staff were required to follow the posted Contact Precaution signage and wear both gown and gloves for any entry or care activity in such rooms, including incontinence care, and that there was no acceptable reason for not following the policy.
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