Infection Control Lapses in Isolation, Catheter, and Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in infection control practices for several residents. For one resident with a post-COVID-19 condition and COPD, staff did not place appropriate signage or a PPE supply cart outside the resident's room to indicate the need for transmission-based droplet precautions. Staff members, including CNAs, entered the resident's room without wearing required PPE, and some were unaware of the resident's isolation status. Interviews revealed that staff did not consistently know or follow the facility's infection control policies regarding isolation precautions. Another resident with severe cognitive impairment and an indwelling urinary catheter received catheter care from a CNA who failed to change gloves and perform hand hygiene after cleaning the resident's buttocks. The CNA continued to handle clean linens and reposition the resident without changing gloves or sanitizing hands. Both the CNA and other staff interviewed acknowledged the importance of glove changes and hand hygiene but did not consistently apply these practices during care. Additionally, a resident with wounds and requiring Enhanced Barrier Precautions (EBP) did not receive care in accordance with EBP protocols. During wound care and incontinent care, staff did not wear gowns as required, despite the presence of indicators (blue name tags) signaling the need for EBP. Staff interviews confirmed knowledge of the EBP requirements but revealed lapses in adherence, with staff admitting to not wearing gowns during high-contact care activities. These failures were observed during direct care and confirmed through staff interviews and record reviews.