Infection Control Deficiency Due to Improper PPE Use and Hand Hygiene
Summary
The facility failed to implement its infection control policy and procedures, leading to a deficiency in preventing the spread of infection among residents. Specifically, the facility did not ensure that a Certified Nurse Assistant (CNA) practiced proper hand hygiene and wore appropriate personal protective equipment (PPE) such as gloves and gowns when entering a resident's room under contact precautions. This lapse was observed when CNA 6 entered Resident 5's room, who was on contact precautions due to a multi-drug-resistant organism (MDRO) infection, without wearing a gown or gloves and without performing hand hygiene before and after the visit. Resident 5, who was admitted with conditions including Chronic Obstructive Pulmonary Disease (COPD) and metabolic encephalopathy, required maximal assistance for activities of daily living and was unable to make decisions. Despite the presence of a contact precaution sign outside Resident 5's room, CNA 6 failed to adhere to the facility's infection control policies. This included not using alcohol-based hand rub or washing hands with soap and water after leaving Resident 5's room and before entering another resident's room, Resident 42, who also had enhanced barrier precautions in place. The facility's policies clearly outlined the need for staff to wear appropriate PPE and practice hand hygiene to prevent the spread of infections, which was not followed in this instance.
Penalty
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Staff failed to follow contact precaution requirements when entering a resident room posted for transmission-based precautions. A staff member was observed inside the room wearing only a KN95 mask, without the required gown and gloves, despite signage instructing use of these PPE items before entry. The unit manager confirmed that the expectation is for staff to wear a gown and gloves in such rooms, and the staff member acknowledged prior education that these PPE components are required. The facility’s written policy on transmission-based precautions also specifies that a gown and gloves must be worn when indicated by the type of isolation, indicating noncompliance with established procedures.
An LPN with long artificial nails repeatedly failed to follow hand hygiene and infection control practices during a med pass involving multiple residents. The LPN handled oral meds directly in the bare hand, including scooping pills from multi‑dose bottles with a fingernail and transferring pills from blister packs into the palm before placing them in cups, and picked up a pill from the top of the med cart with a bare hand. After performing a fingerstick blood glucose check with a glucometer and administering meds, the LPN removed gloves, placed the glucometer on and then into the med cart without disinfecting it, and documented on the computer without performing hand hygiene. The LPN continued to administer meds, prepare MiraLAX, access the treatment cart, and handle wound care supplies while moving between resident rooms, the med cart, and the nurses’ station, all without hand hygiene, contrary to facility policies on handwashing, ABHR use, and fingernail standards.
Staff failed to follow the facility’s Enhanced Barrier Precautions (EBP) policy and a resident’s care plan by not wearing required gowns during a high-contact care activity. A resident with end stage renal disease, chronic kidney disease, and dependence on hemodialysis, with an AV fistula and an order for EBP every shift, had an EBP sign on the door indicating that gowns were required for high-contact activities such as transferring. Two CNAs were observed transferring the resident from a geri-chair to a bed while wearing gloves but no gowns; one CNA stated he usually wears a gown and the other said she was just helping, and an LPN confirmed gowns should have been used. Review of the facility’s EBP policy showed that gowns are required for high-contact care activities, including transferring, for residents meeting EBP criteria.
Staff failed to post required enhanced barrier precaution (EHB) signage for a resident with a tracheostomy and feeding tube who had an active physician order for EHB every shift and documented cognitive impairment. During multiple days of surveyor observation, no EHB sign was present on the resident’s door or wall, even though EHB signs were posted for other residents throughout the facility. A CNA and an RN confirmed that residents with trachs, feeding tubes, PICC lines, or dialysis should be on EHB precautions and that staff had been in-serviced to follow posted signs for high-contact care activities. The RN acknowledged that the resident should have been on EHB precautions and attributed the missing signage to the resident’s recent room change, during which new signage was not put up.
An LPN was observed handling oral medications with bare hands during a medication pass for a resident, contrary to facility policy and infection control protocols. The LPN acknowledged the improper practice, and both the unit manager and infection preventionist confirmed that direct hand contact with medications is not allowed. Facility policy requires the use of a medicine cup rather than hands when administering medications.
Staff failed to follow transmission-based precautions and PPE protocols on two nursing units, including not wearing required isolation gowns when providing care to residents on enhanced barrier or contact precautions, handling medications with bare hands, and not performing hand hygiene after glove removal. Staff interviews revealed confusion about PPE requirements, and the DON confirmed that established infection control policies were not followed.
Failure to Use Required PPE for Contact Precautions
Penalty
Summary
Facility staff failed to follow the facility’s transmission-based precautions policy for contact precautions when entering a resident’s room. During an initial tour, a room with a posted sign instructing staff to use contact precautions, including donning a gown and gloves prior to entry, was observed. Another staff member (OS#1) was seen inside this room wearing only a KN95 mask, with no gown or gloves visible, despite the posted instructions. In a subsequent interview, the unit manager confirmed the expectation that staff wear a gown and gloves when entering such rooms, and OS#1 acknowledged having received education on proper PPE use for contact precautions and stated that a gown and gloves should be worn upon entry. The facility’s written policy on Transmission Based Precautions, effective 12/1/21, states that a gown must be worn when indicated by the type of isolation to protect clothing from contact with contaminated materials and that gloves are to be put on, confirming that the observed practice did not comply with facility policy. No additional resident-specific medical history or condition at the time of the deficiency was provided in the report.
Failure to Follow Hand Hygiene and Glucometer Disinfection Practices During Med Pass
Penalty
Summary
The deficiency involves failure to follow infection prevention and control standards during medication administration on the west wing, involving four residents over a 42‑minute observation period. An LPN with long artificial nails was observed repeatedly handling oral medications with bare hands, including inserting a finger into multi‑dose bottles and using a fingernail to scoop pills out, then placing the pills into a medication cup. On multiple occasions, pills were removed from pharmacy blister cards into the palm of the LPN’s bare hand before being transferred to a medication cup, and a pill that fell onto the top of the medication cart was picked up with a bare hand and placed into the cup. These practices occurred despite facility policies requiring good hand hygiene prior to handling medications and maintaining fingernails short, neat, and trimmed. During blood glucose monitoring and medication administration for one resident, the LPN donned gloves to perform a fingerstick and used a glucometer, but after completing the procedure, disposed of the lancet, medication cup, and gloves, placed the glucometer on top of the medication cart, and began documenting on the computer without performing any hand hygiene. The glucometer was later placed into the medication cart drawer without any cleaning or disinfection. The LPN then proceeded to administer medications to additional residents, again handling medications in the bare hand and entering and exiting resident rooms without performing hand hygiene between residents or before returning to the medication cart and computer. Throughout the observation period, the LPN moved between multiple residents, the medication cart, the nurses’ station, and the treatment cart without performing hand hygiene, despite direct contact with resident environments and equipment. After administering medications and preparing a dose of MiraLAX for another resident, the LPN again failed to perform hand hygiene before accessing the treatment cart drawers and manipulating wound care supplies, which were then taken into a resident’s room. When questioned, the LPN acknowledged the importance of hand hygiene to prevent spreading germs between residents and stated that sanitizer was normally kept in a pocket but was in a bag at that time. Facility policies reviewed by surveyors specified that staff must perform hand hygiene before beginning a medication pass, prior to handling any medication, after direct resident contact, and before and after invasive procedures such as fingerstick blood sampling, as well as maintain appropriate fingernail hygiene.
Failure to Use Required PPE During Enhanced Barrier Precautions Transfer
Penalty
Summary
Facility staff failed to maintain the infection prevention and control program for one resident on Enhanced Barrier Precautions (EBP) by not using all required personal protective equipment (PPE) during a high-contact care activity. Resident #7 had diagnoses including end stage renal disease, type 2 diabetes with chronic kidney disease, and dependence on renal dialysis, and was cognitively intact with a BIMS score of 15/15. The resident had a medical provider order for Enhanced Barrier Precautions every shift related to hemodialysis and an AV fistula in the right forearm, and the comprehensive care plan included a focus on EBP with interventions specifying appropriate PPE per policy and isolation precautions per order. On the survey date, an EBP sign was posted on the resident’s door stating that a gown was required during high-contact patient care activities such as transferring. The surveyor observed two CNAs transferring Resident #7 from a geri-chair to the bed while wearing gloves but not gowns. When questioned, one CNA stated he usually wears a gown, and the other CNA stated she was just helping with the transfer. The LPN who reviewed the EBP sign agreed that gowns should have been donned for this activity. The facility’s EBP policy, effective 3/26/24, required the use of gowns by staff during high-contact care activities, including transferring, for patients who meet EBP criteria, such as those with indwelling medical devices. These observations and document reviews showed that staff did not follow the facility’s EBP policy and the resident’s care plan regarding required PPE.
Failure to Post Enhanced Barrier Precaution Signage for Resident With Tracheostomy
Penalty
Summary
Facility staff failed to implement the ordered enhanced barrier precautions (EHB) for a resident with a tracheostomy. The resident, admitted with diagnoses including tracheostomy status and a feeding tube, had a physician’s order for "Enhanced Precaution r/t Trach every shift" active since 11/04/25. The discharge MDS documented short-term memory loss and moderately impaired cognitive abilities for daily decision-making. During surveyor rounds from 1/12/26 through 1/14/26, no EHB signage was observed on the door or wall of the resident’s room, despite the active order and the presence of a tracheostomy and enteral feeding at the bedside. Staff interviews confirmed that EHB precautions were required for residents with tracheostomies, feeding tubes, PICC lines, or dialysis, and that staff had been in-serviced on following posted EHB signs for high-contact care activities such as dressing, bathing, transferring, changing linens, providing hygiene, changing briefs, device care, and wound care. A CNA described the need to follow EHB signage for such residents, and an RN acknowledged that the resident with a tracheostomy should have been on EHB precautions and that signage should have been posted, explaining that the resident had been moved to another room the previous day and no new signage was put up. Throughout the survey, EHB signs were observed on all floors for other residents, but not for this resident, and facility leadership did not provide additional information to refute the absence of signage.
Failure to Follow Infection Control Practices During Medication Pass
Penalty
Summary
During a medication pass observation on the East unit, an LPN was seen administering oral medications to a resident by removing tablets from supply bottles and handling them directly with bare fingers before placing them in a medicine cup. The LPN had used hand sanitizer prior to starting the medication pass but did not use gloves or another barrier when handling the pills. The medications administered included aspirin, simethicone, omeprazole, and vitamin D. When questioned, the LPN acknowledged that touching pills with bare hands was not a good habit. The unit manager confirmed that nurses were not permitted to touch pills directly during medication administration. The infection preventionist further clarified that pills from bubble packs should be popped directly into the medicine cup, and those from bottles should be poured into the cap and then into the cup, without direct hand contact. Facility policy also specified that staff should use a medicine cup and not their hands when administering medications.
Failure to Implement Transmission-Based Precautions and Proper PPE Use
Penalty
Summary
Facility staff failed to implement proper transmission-based precautions on two of four nursing units, specifically the fourth and fifth floors. Multiple staff members, including nursing students and a certified nursing assistant, entered rooms of residents on enhanced barrier or contact precautions without wearing required personal protective equipment (PPE) such as isolation gowns, despite clear signage and available supplies. In one instance, two staff members assisted a resident with a g-tube and tracheostomy while only wearing masks and gloves, contrary to the posted instructions and physician orders. Another staff member adjusted bed linens for a resident with ESBL in the urine while not wearing an isolation gown, and later exited the room carrying soiled items without removing PPE or performing hand hygiene. Additional deficiencies were observed in medication administration and PPE use. A nurse was seen handling medications with bare hands, and another administered eye drops in the hallway, removed gloves without performing hand hygiene, and then touched shared equipment and medication cards before using hand sanitizer. A respiratory therapist was observed leaving a resident's room in full PPE, accessing a supply cart in the hallway with gloved hands, and then re-entering the room, which was inconsistent with facility policy and infection control practices. Interviews with staff and the Director of Nursing confirmed a lack of adherence to established policies regarding PPE use for enhanced barrier and contact precautions. Staff demonstrated confusion or lack of awareness about the requirements indicated on precaution signage, and the DON acknowledged that proper procedures were not followed in the observed situations. Facility policies reviewed required the use of gowns and gloves for high-contact care activities and specified the need for PPE and hand hygiene to prevent the spread of infection, but these were not consistently implemented.
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