Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
Multiple failures to follow infection prevention and control protocols were observed among staff members during resident care activities. One nurse provided care to a resident on Enhanced Barrier Precautions (EBP) for a right ankle wound without wearing the required isolation gown, despite signage and physician orders indicating the need for EBP. The nurse acknowledged awareness of the requirement but did not comply during close contact with the resident. An X-ray technician, while performing imaging for a resident on EBP, exited the resident's room into the hallway wearing contaminated gloves and an isolation gown to answer a phone call. The technician then returned to the room, removed the PPE, and failed to perform hand hygiene before touching equipment and leaving the room. Facility policy required removal of PPE inside the room and hand hygiene after glove removal, which was not followed. During wound care for another resident, a treatment nurse disposed of contaminated dressings in a regular trash bin instead of a biohazard container, did not perform hand hygiene between glove changes, and used non-sterile scissors to cut a sterile gauze strip for wound packing. The same gloves were used throughout the procedure, and the nurse stated the scissors were disinfected after use. Additionally, a central supply staff member accessed disinfectant wipes from a container without a lid, contrary to facility expectations. These actions were directly observed and confirmed through staff interviews and policy review.