Failure to Maintain Infection Control Practices During Resident Care and Environmental Cleaning
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for two residents, resulting in multiple breaches of standard precautions and environmental cleaning protocols. For one resident with severe cognitive impairment and multiple diagnoses, two CNAs were observed removing urine-soaked sheets from the resident's air mattress, using the soiled sheets to wipe the mattress, and then discarding them on the floor while wearing gloves. The CNAs did not perform hand hygiene or change gloves before proceeding to provide incontinence care and dress the resident in clean clothes. Additionally, the air mattress was not cleaned or disinfected after becoming soiled, contrary to facility policy and staff expectations. In another instance, a resident with cerebral palsy, diabetes, and malnutrition, who was on enteral feeding and Enhanced Barrier Precautions, was found to have an infusion stand soiled with an unidentified brownish substance on multiple occasions. The nursing staff, responsible for changing enteral tube-feed bags and maintaining a clean environment, failed to clean or disinfect the infusion stand as required. Interviews with staff confirmed that the expectation was for the stand to be cleaned with appropriate disinfectant wipes, especially for residents on Enhanced Barrier Precautions. Facility policies reviewed indicated clear requirements for hand hygiene, glove use, and environmental cleaning, with all staff responsible for maintaining cleanliness and reporting issues. Despite these policies and staff awareness of the correct procedures, the observed actions did not align with established infection control practices, resulting in a failure to prevent the potential development and transmission of communicable diseases and infections.