Multiple Lapses in Infection Control and PPE Use
Penalty
Summary
Facility staff failed to maintain proper infection prevention and control practices in several instances. In one case, a treatment nurse provided wound care to a resident on enhanced barrier precautions due to a sacrococcyx pressure sore and exited the resident's room while still wearing an isolation gown. Both the infection preventionist and the director of nursing confirmed that the gown should have been removed before leaving the room, as per facility policy and standard infection control practices. In another instance, a resident on droplet isolation for COVID-19 exposure did not have a trashcan inside the room, making it impossible for staff or visitors to properly doff and dispose of personal protective equipment (PPE) before exiting. The director of social services, infection preventionist, and director of nursing all acknowledged that a trashcan is required inside such rooms to prevent the spread of infection. Additionally, a resident's nasal cannula oxygen tubing was observed lying on the floor, which was recognized by staff as a contamination risk, and the tubing was immediately discarded. Further deficiencies included two residents whose urinals were not labeled with their identifiers, creating a risk of cross-contamination if the urinals were accidentally switched. Staff confirmed that urinals should be labeled with the resident's initials, room, and bed number. Lastly, a certified nurse assistant entered a room under respiratory precautions for COVID-19 exposure without wearing a gown, contrary to posted signage and facility policy, which required full PPE for anyone entering the room.