Failure to Follow Infection Prevention and Control Practices
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed for multiple residents, as observed and documented by surveyors. In one instance, a nurse entered the room of a resident on contact isolation for ESBL of the urine without donning an isolation gown, contrary to the facility's policy and the resident's care plan. Additionally, this resident, who was under transmission-based precautions, was transported to and left in the dining room area for activities, which was not permitted under the facility's policy for residents on such precautions. Another deficiency was observed with a nurse providing care to a resident on enhanced barrier precautions due to the presence of a gastrostomy tube. The nurse failed to change gloves and perform hand hygiene after touching multiple surfaces and before administering medications via the gastrostomy tube and an insulin injection. This was inconsistent with the facility's policy on enhanced barrier precautions, which requires glove and gown use and hand hygiene during high-contact care activities for residents with indwelling medical devices. Further observations revealed that staff did not remove gloves or perform hand hygiene after providing peri-care to three different residents, and subsequently touched the residents' bodies, bed sheets, or applied lotion without changing gloves. These actions were in direct violation of the facility's hand hygiene policy, which mandates hand hygiene after assisting with personal body functions and after glove removal. Interviews with staff confirmed awareness of the correct procedures, but these were not followed during the observed care activities.