Infection Control Lapses in PPE Use, Equipment Sanitization, and Hand Hygiene
Penalty
Summary
Staff failed to consistently follow infection prevention and control protocols, as evidenced by multiple observations and staff interviews. During medication pass, a nurse used a single disinfectant wipe to clean multiple pieces of shared medical equipment, such as a blood pressure cuff, thermometer, and pulse oximeter, without changing the wipe between items. The nurse acknowledged this practice could lead to cross-contamination, and the Director of Nursing indicated that cleaning between residents was primarily emphasized for those on transmission-based precautions, not for all residents. In rooms with Enhanced Barrier Precautions (EBP) and Transmission-Based Precautions (TBP), staff did not properly don or doff personal protective equipment (PPE) as required by facility policy. A housekeeper was observed removing PPE outside the resident's room and discarding it in a housekeeping cart, rather than inside the room as specified. A nurse practitioner and several CNAs entered rooms on droplet and EBP precautions without wearing the recommended PPE, and in some cases, did not perform hand hygiene or change masks after exiting. Staff interviews revealed confusion about when and what type of PPE was required for EBP and TBP, with inconsistent understanding and application of the policies. Additional deficiencies were observed during meal service, where a CNA used a personal bottle of hand sanitizer stored in her pocket between resident tray passes, raising concerns about cross-contamination. The Certified Dietary Manager wore gloves while moving between resident areas and attempted to access doors and nourishment rooms without removing gloves, contrary to infection control protocols. Staff interviews confirmed a lack of clear guidance and understanding regarding glove use, hand hygiene, and PPE requirements during both routine and outbreak situations.