Deficiencies in Infection Control and Hygiene Practices
Penalty
Summary
The facility failed to adhere to proper hygiene and personal protective equipment (PPE) protocols during medication administration and resident care, leading to deficiencies in infection prevention and control. During an observation, a Licensed Practical Nurse (LPN) did not wear a gown while connecting a resident's feeding tube, despite the resident being on Enhanced Barrier Precautions due to a medical condition. The LPN acknowledged the need for gown and gloves but did not comply, citing the task's simplicity as the reason for not wearing a gown. In another instance, a Registered Nurse (RN) failed to perform hand hygiene during a medication administration process. The RN donned clean gloves without washing hands, crushed medications, and handled a medication capsule without performing hand hygiene between glove changes. This oversight was acknowledged by the RN during an interview, indicating a lapse in following the facility's hygiene protocols. The resident involved in the first incident had a history of medical conditions requiring tube feeding and was at risk for nutritional issues. The facility's policies on isolation precautions and hand hygiene were not followed, as evidenced by the staff's actions during the observations. These deficiencies highlight lapses in the facility's infection prevention and control program, as outlined in their policies.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulation the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the center's allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. Immediate Corrective Action: A. Staff A and staff D were immediately re-educated on Control practices. B. Staff A and staff D were re-educated on performing hygiene during care and medication administration and following guidelines for Enhanced Barrier Precautions (EBP) by wearing appropriate Personal Protective Equipment (PPE) during high-contact resident care activities. Identification of other residents potentially affected: Quality Review audit related to control practices was completed. Any issues identified were addressed at that time. No other resident was affected. Measures: On licensed nurses were re-educated on the 5 moments of Hygiene. a. Before patient contact. b. Before a task. c. After exposure risk. d. After patient contact. e. After contact with patient surroundings. Education on control practices and programs have been provided. Handwashing with return demonstration completed for current team members. Re-educated current team members on performing hygiene during care and medication administration and following guidelines for Enhanced Barrier Precautions (EBP) by wearing appropriate Personal Protective Equipment (PPE) during high-contact resident care activities. Prevention and control training will be completed for newly hired team members. Monitoring: The Director of Nursing/ADON Preventionist will conduct weekly random rounds x twelve weeks to monitor for compliance in control practices including hygiene and wearing appropriate Personal Protective Equipment (PPE) during high-contact resident care. The Director of Nursing will report the findings to the Quality Assurance Performance Improvement Committee monthly x 3 months or until the committee determines substantial compliance.