Infection Control Lapses in Hand Hygiene, PPE Use, and Equipment Maintenance
Penalty
Summary
Multiple infection control deficiencies were observed among staff and within the facility environment. One certified nursing assistant (CNA) failed to sanitize her hands before feeding a resident after touching various objects in the resident's room, despite facility policy and infection preventionist statements requiring hand hygiene before resident contact. Another CNA was observed handling soiled linens with gloved hands and then touching clean objects, such as a door knob, curtain, and a resident's glass, and walking into the hallway without removing contaminated gloves or performing hand hygiene, contrary to facility policy and infection control standards. Additional deficiencies included improper management of oxygen equipment and personal protective equipment (PPE). A resident with chronic obstructive pulmonary disease (COPD) was observed using undated oxygen tubing, and another resident's oxygen concentrator filter was found to be dusty, both in violation of facility policies requiring regular dating and cleaning of such equipment. A CNA was also seen wearing a surgical face mask below the nose while in the hallway, which was confirmed as improper by both the CNA and the infection preventionist. Further observations revealed that residents' personal care items, such as wash basins and emesis basins, were not labeled with resident names, creating a risk of cross-use in shared bathrooms. In a room requiring enhanced barrier precautions (EBP), there was no closed lid receptacle for discarding used PPE, despite signage indicating the need for gowns and gloves. Staff interviews and policy reviews confirmed that these practices did not align with facility infection control protocols.