Failure to Follow Infection Control Practices During Norovirus Outbreak
Penalty
Summary
Staff at the facility failed to adhere to proper infection prevention and control practices, particularly regarding hand hygiene and the use of personal protective equipment (PPE). During multiple observations, staff members did not perform hand hygiene at critical points, such as after removing gloves, after touching potentially contaminated surfaces, or before assisting residents with eating. For example, two CNAs were observed changing a resident's soiled brief, touching various items in the resident's environment with contaminated gloves, and then failing to perform hand hygiene after glove removal. Additionally, staff were seen assisting residents with eating and handling food items without sanitizing their hands, even after touching their own hair or after coughing into their hands. The facility also failed to ensure proper implementation and discontinuation of contact precautions for residents with gastrointestinal (GI) symptoms. Staff did not consistently wear required PPE, such as gowns and gloves, when providing care to residents on contact precautions. In one instance, staff were unaware of which resident in a shared room was on contact precautions and did not follow posted signage or use appropriate PPE. Equipment such as full body lifts was not cleaned between uses, and contact precaution signage and supplies were not promptly removed or updated when precautions were discontinued. These lapses in infection control practices occurred during a facility-wide norovirus outbreak, which affected at least 45 residents with confirmed or suspected GI symptoms. The outbreak led to hospitalizations, including one resident who was admitted to the ICU. The facility's own policies required regular staff training, proper hand hygiene, and adherence to transmission-based precautions, but these were not consistently followed as evidenced by direct observations, interviews, and record reviews.