Deficient Infection Control in Central Line Care and Meal Assistance
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were followed during the care of two residents. In one instance, a registered nurse (RN) administered IV medication to a resident with a peripherally inserted central catheter (PICC) line without donning a gown, as required by enhanced barrier precautions. The RN was observed entering the resident's room, which had signage indicating the need for a gown and gloves, but only donned gloves that were taken from their pocket, a practice acknowledged by the RN as an old habit. The resident in question had been admitted with diagnoses including osteomyelitis, discitis, and hepatitis C, and was under enhanced barrier precautions due to the central line. The Director of Nursing (DON) and Infection Control Nurse confirmed that gloves should not be stored in staff pockets and that both gown and gloves are required for such care activities. In another instance, a volunteer providing one-to-one feeding assistance to a resident with dementia and dysphagia failed to perform hand hygiene between assisting the assigned resident and another resident during meal service. The volunteer was observed setting down the resident's utensil, assisting another resident, and then returning to the original resident without washing hands in between. The DON stated that the expectation is for staff providing one-to-one feeding assistance not to assist other residents, but if they do, hand hygiene must be performed between residents. Facility policy on hand hygiene specifically requires hand washing with soap and water before and after assisting a resident with meals. A review of facility policies revealed clear requirements for infection control, including the use of enhanced barrier precautions for central line care and strict hand hygiene protocols during resident meal assistance. Despite these policies and staff training, the observed actions did not align with the established standards, resulting in deficiencies in infection prevention and control practices for the residents involved.
Plan Of Correction
Element 1 R42 no longer resides at the facility, and R15 continues to be assisted by staff and/or volunteers who have been reeducated to perform hand hygiene before and after assisting a resident with meals. Element 2 Residents that reside in the facility have the potential to be affected. An audit was done on the residents with PICC lines to ensure the staff are adhering to Enhanced Barrier Precautions and donning and doffing the appropriate PPE prior to performing any procedures for the PICC line. An audit was done on the residents that require assistance with meals to ensure staff and volunteers only assist one resident at a time and perform hand hygiene before and after assisting any resident. Any areas of deficiencies at the time of the audits will be corrected immediately. Element 3 The Enhanced Barrier Precaution and Hand Hygiene policies were reviewed by the DON and ADON/IC and deemed appropriate. The nurses were re-educated on the Enhanced Barrier Precaution policy and procedures regarding appropriate PPE when taking care of a PICC line. Staff and volunteers were re-educated on the Hand Hygiene policy regarding assistance with meals. Element 4 The ADON/IC and/or designee will complete random audits twice a week for 2 months to ensure nurses are Donning and Doffing appropriate PPE per our policy and procedures while caring for a PICC line. The Administrator and/or designee will complete random audits twice a week for 2 months to ensure that staff and/or volunteers are only assisting one resident at a time and using proper hand hygiene before and after assisting residents with meals. Any areas of deficiencies at the time of the audits will be addressed immediately, and the results of these audits will be presented at the facility's QAPI for further recommendations and/or corrective action. Element 5 Date of compliance 06/27/25. The Administrator and/or designee will be responsible for sustained compliance.