Failure to Follow Contact Precaution PPE Requirements
Penalty
Summary
The facility failed to maintain infection control practices for a resident on contact-precaution isolation when a CNA did not follow required personal protective equipment (PPE) protocols. The resident had chronic respiratory failure and a documented infection with Klebsiella pneumoniae, and a physician’s order dated June 1, 2023, directed contact precautions every shift for CRAB and KPC infection, including wearing a gown and gloves before entering the room or caring for the resident. Facility policy titled “Isolation - Categories of Transmission-Based Precautions,” dated October 2018, required staff and visitors to wear clean, non-sterile gloves when entering the room, to change gloves after contact with infective material, to remove gloves and perform hand hygiene before leaving the room, and to avoid touching potentially contaminated environmental surfaces or items after gloves were removed. On the survey date, signage on the resident’s door indicated the resident was on contact precautions. During observation at 10:45 AM, the CNA was seen in the resident’s room picking up the resident’s call light from the floor without wearing gloves. In a concurrent interview, the CNA acknowledged she had forgotten to wear gloves and stated she understood the importance of wearing gloves to protect herself and the resident. In separate interviews, the ADON and the DSD each stated it was unacceptable for the CNA to be in the contact isolation room without gloves and confirmed that all staff were required to follow the established isolation protocols, including glove use in contact isolation rooms.
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