Failure to Follow Transmission-Based Precautions During Respiratory Outbreak
Penalty
Summary
Surveyors identified a failure to implement transmission-based precautions on one of four nursing units during a confirmed respiratory outbreak. CDC guidance cited in the report recommends Contact Precautions, including use of gloves and gowns, for residents with infections posing increased risk of contact transmission, and Droplet Precautions, including mask use, for residents with infections transmitted by respiratory droplets. The facility’s Infection Prevention and Control Program policy states that important facets of infection prevention include educating staff and ensuring adherence to proper techniques and procedures, and implementing appropriate isolation precautions when necessary. During observation of Unit C, surveyors noted a sign at the unit entrance instructing staff and visitors to wear masks due to a respiratory outbreak, yet staff were seen entering resident rooms without masks while delivering clean laundry. Staff were also observed entering a room with a Contact Precaution sign without any PPE, and moving between rooms without precautions and rooms with droplet precautions in place without donning PPE, despite PPE being available in bins outside every unit where transmission precautions were in place. The DON, who also serves as the Infection Prevention Nurse, confirmed that a respiratory virus outbreak on Unit C had been identified and that all staff were expected to wear masks on outbreak units and follow posted transmission-based precaution signs.
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