Failure to Follow Infection Control Practices During Resident Care and Equipment Handling
Penalty
Summary
Facility staff failed to adhere to infection prevention and control practices for four of five sampled residents, as observed through direct care activities and interviews. For one resident with a history of sepsis, cellulitis, and dementia, a CNA did not wear a gown while providing incontinent care, used the same gloves to touch the resident and room surfaces after care, and did not perform hand hygiene. During wound care for the same resident, a treatment nurse failed to change gloves and perform hand hygiene between removing a soiled dressing and applying a clean one, contrary to facility policy and the resident's care plan for enhanced standard precautions due to MDRO risk. Another resident with a urinary tract infection and dementia was subject to similar lapses. A CNA touched surfaces belonging to another resident and then handled the resident's cup and straw without performing hand hygiene. The same CNA also failed to change gloves and perform hand hygiene after providing peri-care, subsequently touching the resident's hand and bed rail. Interviews with the Infection Prevention Nurse confirmed that these actions did not comply with facility policy and increased the risk of infection transmission. Additional deficiencies included improper management of medical equipment. One resident with an indwelling Foley catheter was observed with the catheter bag resting on the floor, which was confirmed by nursing staff as a violation of policy intended to prevent infection. Another resident receiving respiratory treatments had their mask and nasal cannula stored on top of an undated and unlabeled plastic bag, rather than inside a clean, dated, and labeled bag as required. Staff interviews corroborated that these storage practices did not meet infection control standards outlined in facility policies.