Infection Control Lapses in Multiple Care and Environmental Practices
Penalty
Summary
Staff failed to implement proper infection prevention and control practices in several instances throughout the facility. During a wound dressing change for a resident with a non-pressure chronic ulcer and local skin infection, two nurses changed gloves multiple times without performing hand hygiene between glove changes, contrary to facility policy and infection prevention standards. In another case, a resident with a suprapubic catheter had their urine drainage bag touching the floor and not covered with a protective bag, despite staff acknowledging that this practice increases infection risk. Multiple observations revealed that used basins, bed pans, and urinals belonging to residents were unlabeled and improperly stored on top of toilet tanks or under sinks in shared bathrooms. Staff confirmed these items were not labeled with resident identifiers and cited lack of storage space as the reason for improper storage. Additionally, a nurse used contaminated gloves to administer eye drops to a resident after touching various surfaces, and another nurse placed IV supplies on a visibly soiled overbed table without cleaning it or using a protective barrier. Further deficiencies included improper disinfection practices, such as using the same germicidal wipe to clean both contaminated and uncontaminated surfaces, and staff donning and doffing gloves without performing hand hygiene. A staff member was observed feeding two residents simultaneously without hand hygiene between residents. There were also lapses in transmission-based precautions: signage indicating contact precautions was missing from a resident's door, and a staff member entered the room of a resident on contact isolation without wearing required PPE, despite facility policy and physician orders.