Failure to Follow Infection Control Procedures During Resident Care and Medication Administration
Penalty
Summary
Staff failed to adhere to proper infection prevention and control procedures for two residents on isolation precautions. One resident, who was dependent on staff for all care and had a PEG tube, was placed on Enhanced Barrier Precautions (EBP). During observed care, two CNAs wore gloves but did not don gowns as required by EBP policy while performing a transfer and incontinent care. They also failed to change gloves or perform hand hygiene during or between care tasks. One CNA repeatedly reached into a container of wipes with soiled gloves, contaminating the container. Both CNAs acknowledged during interviews that they did not follow EBP protocols and recognized the risk of contamination. In a separate incident, a resident with diabetes who was dependent on staff for transfers received medication administration from an LPN who did not perform hand hygiene between residents. The LPN touched multiple pills and drinking straws without washing hands between residents. The LPN confirmed during an interview that she failed to perform hand hygiene and understood the importance of this practice in preventing the spread of germs. Facility policy reviews indicated that EBP requires the use of gowns and gloves during high-contact care activities, and that staff are trained on universal precautions and infection control systems. The DON and Infection Preventionist confirmed the importance of following these protocols and that staff had received training on these procedures. However, observations and interviews demonstrated that staff did not consistently implement these infection control measures during resident care.