Failure to Follow Infection Control Practices and Enhanced Barrier Precautions
Penalty
Summary
Facility staff failed to follow safe infection control practices for three out of four sampled residents. In one instance, a student nurse aide entered a resident's room, climbed onto a mattress without wearing any personal protective equipment (PPE), and made direct contact with the mattress using both hands and knees. The aide then adjusted her own clothing and proceeded to touch another resident in the same room without performing hand hygiene before or after resident contact. The aide confirmed that she did not use PPE as required for high-contact activities, despite signage indicating the need for gowns and gloves during such care for residents on Enhanced Barrier Precautions (EBP). The Assistant Director of Nursing, who was present, acknowledged not instructing the aide to use PPE. In another instance, a resident with a foley catheter and a wound did not have EBP signage or PPE available outside the room, as required by facility policy. During care, a certified nurse assistant handled the resident's foley catheter tube with bare hands and attempted to reattach it without gloves. The infection preventionist confirmed that the resident should have been on EBP and that the necessary signage and PPE were missing. The CNA later acknowledged that gloves should have been worn during the procedure.