Failure to Follow Infection Control and PPE Protocols
Penalty
Summary
Multiple instances of staff failing to follow infection prevention and control protocols were observed during direct resident care. One staff member provided feeding assistance to two residents, moving between them and handling their food, utensils, and personal items without performing hand hygiene between contacts, despite facility policy and expectations requiring hand hygiene to prevent cross-contamination. Another staff member was observed assisting a resident with toileting and incontinence care, using the same gloves to handle soiled items, clean the resident, retrieve clean clothing, and assist with dressing, without changing gloves or performing hand hygiene between dirty and clean tasks. This same staff member, along with another, also failed to change gloves or perform hand hygiene when moving from soiled to clean areas during incontinence care for a different resident. Additional deficiencies were noted in the use of personal protective equipment (PPE) for residents on isolation or enhanced barrier precautions. Staff and a vendor entered a resident's COVID-19 isolation room without wearing the required N95 mask, face shield, or gown, and failed to perform hand hygiene upon exiting the room. The isolation room door was left open on multiple occasions, contrary to facility policy and staff training. Staff also failed to educate a vendor on proper PPE use before allowing entry into the isolation room. In another case, staff provided care to a resident on enhanced barrier precautions wearing only gloves, omitting the required gown and mask during high-contact activities such as incontinence care, dressing, and transferring. Facility policies reviewed indicated clear requirements for hand hygiene before and after resident contact, after handling soiled items, and when moving between dirty and clean tasks. Policies also specified the use of full PPE, including N95 masks, gowns, gloves, and face shields for COVID-19 isolation, and gowns and gloves for enhanced barrier precautions during high-contact care. Despite these policies and staff knowledge of the requirements, the observed failures to adhere to infection control protocols involved multiple staff members and affected several residents, including those with significant medical needs such as hemiplegia, cellulitis, and indwelling medical devices.