Infection Control Deficiencies in Equipment Handling, PPE Use, and Hand Hygiene
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's infection prevention and control practices. Staff failed to properly store respiratory equipment, such as passive masks and tubing, for several residents. In multiple instances, these items were left unbagged on surfaces or on the floor, contrary to facility policy and staff expectations that such equipment should be bagged when not in use. Additionally, disposable equipment was not consistently labeled or changed as required. Staff did not consistently adhere to enhanced barrier precautions (EBP) for residents with medical devices or those requiring such precautions. Certified Nursing Assistants (CNAs) and Licensed Practical Nurses (LPNs) were observed providing direct care, including dressing, toileting, and medication administration, to residents on EBP without wearing the required gowns, and in some cases, staff were unaware that residents were on EBP. The Director of Nursing (DON) confirmed that staff are expected to wear both gloves and gowns when providing care to residents under EBP, and that some residents who met criteria for EBP did not have appropriate orders in place. Hand hygiene and equipment cleaning protocols were not followed during resident care and medication administration. Staff were observed changing gloves multiple times without performing hand hygiene in between, despite facility policy and DON statements that hand hygiene is required between glove changes. Medical equipment, such as blood pressure cuffs and pulse oximeters, was used on multiple residents without cleaning between uses. Additionally, staff handled oral medications with bare hands and administered medications that had dropped onto unclean surfaces. These actions were inconsistent with facility policies and accepted standards for infection prevention and control.