Failure to Adhere to Infection Control Protocols and Safe Handling of Medical Products
Penalty
Summary
The facility failed to adhere to infection prevention and control protocols in several observed instances. Staff did not follow posted Enhanced Barrier Precautions signage, such as failing to wear gowns and gloves when required for residents with wounds or devices like G-tubes. In one case, a disposable gown was left hanging in a resident's room, and staff were unaware of its purpose or the need for proper use of personal protective equipment (PPE). Multiple staff members, including CNAs and LPNs, entered rooms or provided care without donning appropriate PPE, despite clear signage and physician orders indicating the need for enhanced precautions due to conditions such as recent C. difficile infection, surgical wounds, or G-tube presence. Hand hygiene practices were not consistently followed during medication administration and wound care. An LPN was observed retrieving and administering medication to a resident without performing hand hygiene after touching multiple surfaces, including a medication dispensing machine and secured doors. During wound care, the Assistant Director of Nursing did not change gloves or perform hand hygiene between cleaning the wound and applying ointment and a new dressing, contrary to established infection control procedures. Additionally, the facility did not properly handle or store tube feeding products according to manufacturer recommendations. Observations revealed that tube feeding bottles were left open, undated, and uncovered in resident rooms, and staff did not ensure that these products were refrigerated or used within the recommended timeframe. These lapses were confirmed by staff interviews and were not in accordance with facility policy or manufacturer guidelines.