Failure to Follow Infection Control Protocols and Equipment Disinfection
Penalty
Summary
Staff failed to follow established infection prevention and control protocols during resident care, particularly for those on contact isolation precautions and when taking vital signs. In multiple observed instances, staff entered the rooms of residents on contact isolation without wearing the required personal protective equipment (PPE), such as gowns and gloves, and only wore masks. Staff acknowledged forgetting to use the appropriate PPE when entering these rooms, despite facility policy requiring full PPE for contact isolation. Additionally, staff did not properly disinfect medical equipment, such as blood pressure (BP) machines and pulse oximeters, before and after use between residents. In several cases, staff took portable BP machines from the hallway, used them on residents without prior disinfection, and returned them to the hallway without cleaning. This practice was observed with multiple staff members, including LPNs and RNs, who admitted to forgetting to disinfect the equipment as required by facility policy. For residents on transmission-based precautions, such as those with active COVID-19 infections, the facility failed to provide dedicated disposable vital sign equipment inside the resident's room. Instead, vital sign equipment was removed from isolation rooms and used elsewhere, contrary to facility policy that mandates dedicated equipment remain in the room until isolation is discontinued. These lapses were confirmed by interviews with the infection preventionist, DON, and ADON, who all stated that staff should follow proper PPE and disinfection protocols, and that dedicated equipment should be used for residents on isolation precautions.