Failure to Maintain Infection Control Practices and Proper PPE Use
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for two residents, resulting in multiple observed deficiencies. In one instance, a CNA provided incontinence care to a female resident with severe cognitive impairment and chronic medical conditions, including COPD, diabetes, and hemiplegia. After removing a soiled brief and cleaning the resident's perineal and buttock areas, the CNA did not change gloves before placing a clean brief under the resident, despite handling contaminated materials. The CNA only removed gloves and washed hands after completing the care, which was confirmed during interviews with both the CNA and the DON. In another case, an LVN performed colostomy care for a female resident with severe cognitive impairment, dementia, and a history of COVID-19 and intestinal obstruction. After cleaning feces from the resident's stoma, the LVN changed gloves but did not sanitize or wash hands before donning new gloves and applying a new colostomy bag. The LVN acknowledged during interview that hand hygiene should have been performed between glove changes, and the DON confirmed this expectation. Additionally, the facility did not ensure that staff wore appropriate PPE when entering the room of a resident on aerosol isolation precautions due to COVID-19 exposure. Two staff members were observed entering the room wearing only regular face masks, gowns, and gloves, rather than the required N95 respirators and eye protection. They also improperly removed and transported contaminated PPE and trash out of the isolation room. Interviews with the staff, DON, and Administrator revealed confusion and lack of adherence to the facility's posted isolation protocols, which required specific PPE and disposal procedures to prevent cross-contamination.