Infection Control Lapses in PPE Use, Equipment Disinfection, and Supply Handling
Penalty
Summary
Facility staff failed to adhere to established infection prevention and control protocols in several instances. Two CNAs did not wear the required gowns, only gloves, while providing care to a resident on Enhanced Barrier Precautions (EBP) for an arteriovenous shunt used in dialysis. The EBP signage and facility policy clearly indicated that both gown and gloves were required for high-contact activities such as dressing and transferring, and both CNAs acknowledged awareness of these requirements. The Infection Preventionist and Director of Nursing confirmed that the expectation was for staff to wear both gown and gloves during such care, and records showed both CNAs had received recent in-service training on EBP prior to the incident. A licensed nurse failed to disinfect a blood pressure cuff between uses on three different residents during medication administration. The nurse used the same cuff on each resident consecutively without cleaning it, and later acknowledged this lapse. Facility policy required that multi-resident use equipment be cleaned and disinfected after each use, but this was not followed in these instances. During a wound care procedure, a nurse placed excess treatment supplies, including opened packs of gauze and silicone foam dressings, back into the treatment cart after use in a resident's room. Both the nurse and the Infection Preventionist confirmed that this practice could lead to cross-contamination, and facility policy specified that supplies removed from the cart and exposed during treatment should not be returned unless sanitized. The Director of Nursing also stated that returning such supplies to the cart was not appropriate due to the risk of spreading infection.
Plan Of Correction
a) On 04/09/2025 CNA 1 and CNA 2 immediately put on PPE required for Resident 73's Enhanced Barrier Precaution. b) On 04/08/2025 Licensed Nurse 9 immediately cleaned and disinfected the blood pressure cuff. c) On 04/08/2025 Licensed Nurse 1 removed and disposed of the excess treatment supplies from the treatment cart. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: d) Infection Prevention Nurse Consultant completed an audit on 04/09/2025 of staff to ensure no other staff were identified with having the same deficient practice of not wearing enhanced barrier precaution PPE. No other areas were identified with having the same deficient practice. e) Infection Prevention Nurse / designee completed an audit on 04/09/2025 of staff to ensure no other licensed nurses were identified with having the same deficient practice of not cleaning and disinfecting the blood pressure cuff between residents. No other areas were identified with having the same deficient practice. f) Infection Prevention Nurse / designee completed an audit on 04/09/2025 of staff to ensure no other licensed nurses were placing excessive treatment supplies back into the treatment cart. No other areas were identified with having the same deficient practice. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: g) DON in-served Licensed Nurses on 04/17/2025 regarding the importance of wearing enhanced barrier precaution PPE, cleaning and disinfecting resident equipment between uses, and not putting excess treatment supplies back into the treatment cart. h) Infection Preventionist and/or designee will conduct random audits of staff to ensure that enhanced barrier precaution PPE is worn, disinfecting of resident equipment between uses, and excess treatment supplies are not placed back into the treatment cart. All non-compliance issues identified during these audits will be brought forth to the department managers five days a week morning meeting for review, validation, and immediate correction. Infection Preventionist will do a trending/analysis and will report quarterly to the QAPI Committee for further evaluation and/or recommendation/s. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system: i) Infection Preventionist and/or designee will conduct random audits of staff to ensure that enhanced barrier precaution PPE is worn, disinfecting of resident equipment between uses, and excess treatment supplies are not placed back into the treatment cart. All non-compliance issues identified during these audits will be brought forth to the department managers five days a week morning meeting for review, validation, and immediate correction. Infection Preventionist will do a trending/analysis and will report quarterly to the QAPI Committee for further evaluation and/or recommendation/s. 04/17/2025