Infection Control Lapses in PPE Use, Hand Hygiene, and Equipment Handling
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by multiple observed lapses in the use of personal protective equipment (PPE), hand hygiene, handling of incontinence care supplies, and storage of respiratory equipment. Staff did not consistently don gowns and gloves when providing high-contact care to residents on enhanced barrier precautions (EBP), including those with feeding tubes and other indwelling devices. For example, a certified nursing assistant (CNA) provided hands-on care to a resident with a feeding tube without wearing any PPE, despite clear care plan and physician orders requiring EBP. The CNA was unaware the resident was on EBP, and this was later confirmed by the Director of Nursing (DON). Additional deficiencies were observed in the handling of incontinence care and hand hygiene. One CNA left a resident's room wearing soiled gloves and gown, touched clean linen carts, and returned to the resident's room with soiled gloves in hand, confirming she had contaminated clean supplies. Another CNA failed to wash hands before, during, or after providing incontinence care to two residents, did not properly use PPE, and handled clean and soiled items with contaminated gloves. Shared wash basins were left uncovered and unmarked on the floor, and were not cleaned or labeled as required, creating a risk of cross-contamination between residents. The DON confirmed that staff were required to don PPE for EBP and perform hand hygiene, and that wash basins should be cleaned, labeled, and not shared or stored on the floor. Medication administration practices also failed to meet infection control standards. A registered nurse (RN) did not perform hand hygiene before preparing or administering medications to two residents, and there was no hand sanitizer available on the medication cart. Additionally, a resident's BIPAP mask was found on the floor after being knocked off the nightstand, and a nurse confirmed it was not stored in a sanitary manner. Facility policies reviewed required hand hygiene before and after resident contact, proper use of PPE, and adherence to infection control procedures during medication administration, all of which were not followed in these instances.