Failure to Maintain Infection Control Practices During Resident Care
Penalty
Summary
Staff failed to maintain proper infection prevention and control practices during the provision of care for two residents. In one instance, a certified nursing assistant (CNA) provided morning care to a resident with a seizure disorder and malnutrition who had urinated and had a bowel movement in bed. The CNA donned gloves but did not have wipes or a garbage can nearby, touched multiple surfaces with soiled gloves, and changed gloves four times without performing hand hygiene between changes. Hand sanitizer was not readily available in the resident's room, and the CNA acknowledged not performing hand hygiene during glove changes or after touching contaminated items. In another case, a resident with diabetes, MRSA, and cellulitis, who was on enhanced barrier precautions (EBP) due to venous wounds and a MRSA infection, was transferred from bed to toilet by a CNA and an LPN. Both staff members donned gloves but did not wear gowns as required by the EBP and contact precautions signage posted on the resident's door. The staff were observed transferring the resident without the appropriate PPE, and both later confirmed they did not follow the signage instructions, with the LPN expressing confusion about which sign to follow. The Director of Nursing (DON) confirmed that staff should perform hand hygiene when moving from dirty to clean tasks and when donning new gloves, and that gowns should have been worn during the transfer for a resident on EBP and contact precautions. The DON also acknowledged that hand sanitizer was not accessible in resident rooms and that infection control audits were primarily conducted on other shifts, not during the night shift when the deficiencies were observed.