Failure to Provide PPE and Maintain Infection Control Protocols
Penalty
Summary
The facility failed to ensure proper implementation of infection prevention and control protocols for several residents requiring Enhanced Barrier Precautions (EBP). For three residents with significant medical conditions, including dementia, cancer, immunodeficiency, and recent surgical wounds, there was no personal protective equipment (PPE) visibly available at the point of care, despite signage indicating EBP requirements. Alcohol-based hand rub (ABHR) dispensers in these residents' rooms were not functioning, and staff were unaware of the EBP requirements, admitting to not donning PPE during care. PPE was stored in locations inaccessible to direct care staff, and staff had to rely on nurses to access PPE from a storeroom. The Director of Nursing confirmed that PPE was mixed with residents' clothing in wardrobes, and that staff were not using gowns as required. Additionally, the facility failed to maintain infection control during peri-care for a resident with immunodeficiency and end-stage renal disease. Certified Nursing Assistants (CNAs) were observed cleansing the resident's perineal area and buttocks from back to front multiple times, contrary to infection control protocols which require cleansing from front to back. The Director of Nursing confirmed that the correct procedure was not followed during peri-care. These failures were identified through observations, interviews, and record reviews, and were not limited to a single staff member or shift.