Infection Control Lapses in Hand Hygiene, Medication Handling, PPE Availability, and C-Diff Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in infection control practices. During a wound dressing change for a resident with a history of stroke, dementia, and total dependence for activities of daily living, a nurse repeatedly failed to perform hand hygiene before donning new gloves, despite facility policy requiring hand hygiene before and after glove changes. The nurse continued the dressing change process, including cleaning the wound and applying skin prep, with potentially contaminated gloves, which was acknowledged as incorrect during subsequent interviews. Additionally, during a medication pass, a nurse was observed opening an acidophilus capsule with bare hands, potentially contaminating the medication. The nurse believed that hand sanitization prior to handling the medication was sufficient, but the Director of Nursing clarified that medications should never be touched with bare hands. Another observation revealed that personal protective equipment (PPE) was not readily available outside a resident's room where enhanced barrier precautions were indicated, contrary to facility expectations that a PPE cart be present for staff use. For a resident who developed symptoms and tested positive for Clostridioides difficile (C-Diff), the facility failed to implement contact precautions promptly. Although the resident had reported diarrhea and later tested positive for C-Diff, contact precautions, including signage and a PPE cart, were not put in place until 48 hours after the positive test result. Interviews confirmed that contact precautions should have been initiated when symptoms began and while awaiting laboratory results, but this was not done in a timely manner.