Failure to Adhere to Infection Control Practices for Droplet Precautions and Dining Services
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices related to droplet precautions for six residents. Staff members, including CNAs, QMAs, and dietary aides, entered rooms with droplet precaution signage without donning required personal protective equipment (PPE) such as eye protection, and in several instances, did not perform hand hygiene upon exiting the rooms. Some staff members were observed entering rooms without first ensuring PPE was available, and others misunderstood or disregarded the requirements for face shields or goggles, despite clear signage and facility policy. These lapses occurred even though residents had active physician orders and care plans for droplet precautions due to diagnoses such as Influenza A, bronchitis, pneumonia, and other respiratory illnesses. The residents involved had varying degrees of cognitive and physical impairment, with some being dependent on staff for mobility and care. Additionally, during dining services, staff failed to follow infection control protocols while assisting residents with meals. One CNA was observed touching her face, handling multiple residents' utensils and cups without performing hand hygiene, and blowing on food before serving it to residents. The CNA also used the same utensils between residents and touched the tops of cups and bowls, contrary to facility policy and infection control standards. Interviews with staff and the Infection Preventionist confirmed that these actions were not in line with expected practices, which require frequent hand hygiene, avoidance of bare-hand contact with food, and not sharing utensils among residents. Facility policies reviewed by surveyors indicated clear requirements for transmission-based precautions, including the use of appropriate PPE and hand hygiene. The observed failures to adhere to these policies and CDC guidelines were confirmed through staff interviews, which revealed gaps in understanding and inconsistent application of infection control measures. These deficiencies had the potential to affect all residents on droplet precautions and those receiving dining assistance.