Failure to Follow Infection Control and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper infection control practices were followed during care activities involving two residents. In one instance, a registered nurse administered eye drops to both eyes of a resident with severe cognitive impairment without changing gloves or performing hand hygiene between each eye, contrary to facility policy which requires hand hygiene before treating each eye. This lapse was observed during medication administration and confirmed by the Director of Nursing, who stated that gloves should be changed and hand hygiene performed between eyes. In another instance, a certified nursing assistant did not follow Enhanced Barrier Precautions (EBPs) while providing care to a resident with multiple risk factors for infection, including an indwelling catheter, a PICC line, a stage 3 pressure ulcer, and a history of antibiotic use. The CNA was observed in the resident's room without wearing a gown, despite signage indicating EBPs were required. Additionally, a soiled brief was left unbagged on the floor, and privacy measures were not maintained. Both the LPN and DON confirmed that proper PPE, including gown and gloves, should have been used and that soiled items should not be left on the floor.