Infection Control Lapses in PPE Handling and Disinfection
Penalty
Summary
The facility failed to ensure proper infection control practices were followed by staff, as observed in two resident care areas. Employees 7 and 8 were seen wearing protective gowns while providing care to a resident on enhanced barrier precautions. However, they exited the resident's room still wearing the gowns and disposed of them in a hallway garbage can, contrary to the facility's policy that requires PPE to be removed before leaving the room. The Nursing Home Administrator acknowledged the expectation that gowns and gloves should be removed inside the room and placed in a garbage bag before disposal in the hallway. In another incident, Employee 6 completed a dressing change for a resident with a pressure ulcer but failed to disinfect the bedside table after placing a biohazard garbage bag on it. The Nursing Home Administrator confirmed that the expectation was for the bedside table to be cleansed after contamination. Additionally, during a dressing change for another resident, Employee 15 and Employee 19 exited the room wearing gowns and gloves, with Employee 15 handling a red biohazard bag with her bare hand after removing her gloves in the hallway. This action was identified as an infection control concern by the Nursing Home Administrator. The report also highlighted that Employee 15 was unaware of when the key used to access a utility closet was last cleaned, raising further infection control concerns. The Nursing Home Administrator confirmed that staff should remove PPE inside the room and dispose of it properly to prevent contamination. These observations indicate lapses in adherence to infection control policies, potentially increasing the risk of infection spread within the facility.
Plan Of Correction
Residents 24, 12, 37 have been evaluated for signs of infection - no symptoms noted. Surfaces in resident rooms have been properly disinfected. All residents will be monitored for symptoms of infection via review of nursing documentation and daily staff observations with care. All bedside tables have been disinfected. Enhanced barrier precautions and contact precautions policies updated to include staff will doff personal protective equipment prior to leaving resident room, place in a trash bag and dispose of in trash receptacle in hallway. Red bag receptacles will be placed in all resident rooms for residents requiring a dressing change or other care when trash may be soiled with blood or body fluids. Treatment application policy updated to include disinfecting all surfaces after completion of treatments. All staff will be educated on enhanced barrier precautions and contact precautions policies. Nursing staff will be educated on treatment application policy. Unit reviews by nursing supervisors will be completed to ensure compliance. A QA tool has been developed to review 10% of treatment applications weekly to ensure compliance with enhanced barrier precautions, contact precautions and treatment application policies to ensure compliance. The Quality Assurance (QA) Coordinator or designee will complete the QA review on a weekly basis and re-educate staff not following policy and procedure. The QA Coordinator will review the completed QA tool monthly and will report any trends or patterns at the quarterly Interdisciplinary Quality Assurance and Quality Performance (QAPI) meeting. The QAPI Committee will review the reports at their quarterly meeting and make recommendations for any deficient patterns identified. They will continue to monitor quarterly until the solutions are sustained for a period of two quarters. Decreasing or elimination of this tool will occur only upon recommendation of the Interdisciplinary QAPI Committee at their quarterly meeting.