Failure to Follow Infection Control Protocols for Contact Precautions, Equipment Storage, and Hand Hygiene
Penalty
Summary
The facility failed to adhere to infection prevention and control guidelines in several observed instances. For one resident on contact precautions due to a urinary tract infection with ESBL, a registered nurse entered the resident's room wearing only gloves, without donning a gown as required by the facility's contact precaution policy. The nurse administered an intramuscular injection and then, after removing her gloves, repositioned the resident and handled linens without appropriate personal protective equipment or hand hygiene between tasks. Additionally, two residents receiving nebulizer treatments were found to have their nebulizer tubing and masks stored uncovered on their bedside dressers. One resident confirmed that after a recent treatment, the equipment was left uncovered, while the other resident stated the equipment was supposed to be stored in a bag but was not. These observations indicate improper storage of respiratory care equipment, contrary to infection control protocols. In another instance, a certified nursing assistant performed catheter care for a resident with an indwelling urinary catheter. During the procedure, the resident had a bowel movement, resulting in the CNA's gloves becoming soiled. The CNA changed gloves multiple times during the procedure but did not perform hand hygiene between glove changes, despite facility policy and standard infection control practices requiring hand hygiene at these points.