Widespread Infection Control Failures and Lapses in PPE Use
Penalty
Summary
Multiple deficiencies in infection prevention and control practices were observed throughout the facility. Staff failed to maintain proper handling of medical equipment, such as allowing a urinary catheter drainage bag to touch the floor and leaving oxygen tubing and enteral feeding tube tips exposed or improperly stored. In several instances, staff did not perform hand hygiene or change personal protective equipment (PPE) between resident care tasks, including when assisting with meals, handling invasive devices, or entering and exiting isolation rooms. There were also failures to don appropriate PPE when entering rooms of residents on contact or COVID-19 precautions, and improper use of disinfectant wipes for hand hygiene was noted. Communication lapses were identified, such as the failure to notify a dialysis center of a resident's isolation status and infection type. Signage and isolation carts for contact precautions were either missing or not clearly visible at room entrances, and PPE was not always readily accessible. Staff were observed entering contact precaution rooms without proper PPE, and in one case, a staff member used hand sanitizer instead of washing hands with soap and water after contact with a resident with C. difficile infection, contrary to CDC guidelines. Additionally, a registered nurse was observed wearing a double mask (N-95 over a surgical mask) when only an N-95 was required, potentially compromising the effectiveness of the respirator. Further deficiencies included improper cleaning and disinfection of shared medical equipment, such as using alcohol wipes instead of the required disinfectant for glucometers, which may not be effective against certain bloodborne pathogens. Staff also failed to ensure that oxygen cannulas not in use were stored properly, and that oxygen tubing was not entangled or lying on the floor. These actions and inactions were directly observed and confirmed through staff interviews and review of facility policies, highlighting widespread non-compliance with established infection control protocols.