Deficient Infection Control Practices and PPE Use
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's infection prevention and control practices, specifically related to the use of personal protective equipment (PPE) and adherence to Enhanced Barrier Precautions (EBP). During care for two residents, staff failed to don required PPE gowns while performing high-contact care activities, such as changing briefs and providing perineal care. In one instance, a certified nursing assistant (CNA) entered a resident's room to answer a call light and performed care without wearing a gown, despite the presence of an EBP sign. The CNA also failed to change her mask after touching it with a gloved hand. Another CNA confirmed that gowns and gloves are required for care activities under EBP, but not for answering call lights, indicating inconsistent understanding and application of the policy. Further observations revealed that a registered nurse (RN) did not perform hand hygiene before entering a resident's room for a check, donned PPE, and then cleaned a piece of equipment with tissue paper soaked in sanitizer, contrary to facility policy. The facility's policy required the use of specific cleaning agents and procedures, which were not followed. Additionally, two certified nurse assistants performed care for another resident without wearing PPE gowns, and one of them changed gloves without performing hand hygiene between tasks. The survey also found that appropriate means for disposing of used PPE were not provided in a resident's room who was on isolation for COVID-19. The only waste receptacles available were small, uncovered containers, and there was no designated bin for PPE disposal as required by facility policy and CDC guidelines. Interviews with staff and the infection preventionist confirmed the lack of proper receptacles and inconsistent practices regarding PPE removal and disposal. These deficiencies were observed across multiple staff members and residents, indicating systemic issues with infection control protocols.
Plan Of Correction
On , the Staff Development Coordinator provided 1:1 education to Staff G on proper Enhanced Barrier Precautions. On , the Staff Development Coordinator provided 1:1 education for Staff I on Enhanced Barrier Precaution. On , the Staff Development Coordinator provided 1:1 education to Staff L on the proper procedure to and proper hygiene. On , Staff J was given 1:1 education on proper PPE uses for a resident on EBP and proper hygiene. On , Staff Q was given 1:1 education on proper PPE uses for a resident on EBP and proper hygiene. On , a receptacle with a lid was placed in room of resident #95. On , the Staff Development Coordinator conducted a quality review of residents on Enhanced Barrier Precautions to ensure staff are utilizing appropriate PPE and hygiene. On , the Staff Development Coordinator conducted a quality review of residents on transmission-based precautions to ensure that proper waste receptacles were present for staff to discard used PPE. No additional findings were noted. On , the preventionist conducted a quality review of in the center to ensure that they were properly. By , the Staff Development Coordinator educated the current staff on the components of F880 with an emphasis on Proper Donning and Doffing of PPE, Proper adherence to Enhanced Barrier Precautions, and Proper Hygiene. On , the DON educated the ADON/IP on the components of F880 with emphasis on placement of the proper waste receptacles for PPE disposal. By , licensed nurses were educated on the components of F880 with an emphasis on proper technique of by the Staff Development Coordinator. As a part of a systematic change, newly hired staff will be educated on the components of F880 with an emphasis on Proper Donning and Doffing of PPE, Proper adherence to Enhanced Barrier Precautions, and Proper Hygiene. As part of a systematic change, newly hired Preventionists will be educated on F880 with emphasis on placement of the proper waste receptacles for PPE disposal. As part of a systematic change, newly hired licensed nurses will be educated on the components of F880 with an emphasis on proper technique of . The DON/designee will conduct 5 random observations of gown donning and doffing x 4 weeks, then 10 random observations of gown donning and doffing monthly x 2 months to ensure that gowns are being properly worn during high contact care activities. DON/Designee will conduct 10 random hygiene observations weekly x 4 weeks and then 20 random hygiene observations monthly x 2 months to ensure that proper hygiene is performed. DON/designee will conduct 5 observations of cleaning weekly x 4 weeks then 10 observations of cleaning monthly x 2 months to ensure proper of equipment. The findings of these quality monitoring to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met. F 880 F 880 F 880