Infection Control Lapses in PPE Use, Hand Hygiene, and Equipment Disinfection
Penalty
Summary
Multiple instances of non-compliance with infection prevention and control protocols were observed among nursing staff during resident care activities. In several cases, staff failed to don required personal protective equipment (PPE), such as gowns and gloves, when providing wound care to residents on Enhanced Barrier Precautions due to open wounds. For example, a nurse entered a resident's room to perform heel wound treatment without wearing a gown, despite signage and physician orders indicating the need for enhanced precautions. In another instance, a wound nurse practitioner provided pressure ulcer care without wearing a gown and handled supplies and equipment in a manner inconsistent with infection control policies. Hand hygiene lapses were also documented, including staff donning gloves without prior hand cleansing, changing gloves without performing hand hygiene in between, and handling clean and soiled items with the same gloves. During medication administration, a nurse was observed dumping pills into her gloved hand before placing them in medication cups, which is not in line with proper hand hygiene and medication handling procedures. Additionally, reusable medical equipment such as scissors was not consistently disinfected between uses, and clean barriers were not always used when placing supplies on resident surfaces during wound care. Facility policies require the use of specific disinfectants for non-critical items, preparation of clean work areas with protective barriers, and strict adherence to hand hygiene before and after resident contact, glove changes, and handling of clean or soiled dressings. The observed practices deviated from these policies, as staff failed to consistently follow established protocols for PPE use, hand hygiene, and equipment disinfection during high-contact resident care activities, particularly for residents with wounds or on enhanced barrier precautions.