Failure to Use PPE During Contact Isolation Precautions
Summary
Nursing staff failed to wear required personal protective equipment (PPE), specifically gloves and a gown, when delivering and removing a lunch tray for a patient who was on contact isolation due to an infectious disease. Observation showed a Certified Nurse Assistant (CNA) entering the patient's room without donning PPE, and later accepting an empty lunch tray from the patient without gloves. The CNA acknowledged this was a breach of the facility's contact isolation protocol, which is intended to prevent the spread of infection. The patient involved had been admitted with diagnoses including shortness of breath and cellulitis of the back, and required supervision for several activities of daily living. Facility policy, as well as statements from the Director of Nursing (DON), confirmed that staff are required to wear full PPE when entering the room of a patient on contact isolation, including when handling food trays. The facility's policy also indicated that PPE should be readily available near the entrance to the patient's room and must be donned before or upon entry.
Plan Of Correction
C1245: T22 DIV5 CH3 ART3-72321(a) Nursing Service - Patients with infectious disease Corrective action for resident found to have been affected by this deficiency. On 3/10/2025, CNA 1 was provided 1:1 education regarding transmission-based precaution requirements and encouraged to perform prompt hand hygiene. Identify any other residents who may have been affected by the deficient practice. On 3/10/2025, DSD and IP made rounds of all isolation rooms in the facility to ascertain if there were any other staff members entering contact isolation rooms without proper PPE. There were no other issues identified. Measures that will be put into place to ensure that this deficiency does not recur. Beginning 3/10/2025, IP initiated in-servicing to CNA and licensed nursing staff regarding proper PPE use as indicated when delivering or picking up meal trays. (To continue page 15 of 25) Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur. Beginning 3/10/2025, IP will perform weekly rounding of all isolation rooms to ascertain if staff is utilizing PPE as indicated. These rounds will continue for 1 month or until substantial compliance is obtained. Any ongoing issues will be reported by IP nurse at the monthly QA meeting. Date of corrective action would be completed. 04/03/25 C1245
Penalty
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