Failure to Adhere to Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff not adhering to established protocols for personal protective equipment (PPE) and wound care. Specifically, staff did not wear gowns when providing direct care to a resident on enhanced barrier precautions (EBP), despite facility policy requiring both gloves and gowns for high-contact care activities involving residents at risk for or colonized with multi-drug resistant organisms (MDROs). Observations showed that a certified nurse aide and two LPNs provided care to a resident on EBP while only wearing gloves, omitting the required gown. Additionally, infection control measures were not followed during wound care procedures. One LPN used scissors from her pocket to cut wound dressing without sanitizing them before use, and another LPN used a retractable tape measure to measure an open wound, then retracted and stored it without sanitization. Wound care supplies were also placed directly on a resident's nightstand among personal items, rather than on a clean surface. Staff interviews confirmed that these actions were inconsistent with facility policy and best practices for infection control.