Failure to Follow Infection Control Guidelines During Resident Care
Penalty
Summary
The facility failed to adhere to infection prevention and control guidelines for three residents during direct care activities. In one instance, an LPN provided tracheostomy care to a resident with a history of stroke, quadriplegia, and respiratory failure, and then, without changing gloves or performing hand hygiene, proceeded to remove and clean the resident's gastrostomy tube dressing. The LPN also left the resident's room wearing the same gown, walked down the hall, and returned still wearing the gown to complete the dressing change, contrary to facility policy and infection control protocols. In another case, the same LPN performed a wound dressing change for a resident with cancer, coronary artery disease, and two Stage II pressure ulcers. After removing the old dressing, the LPN failed to sanitize her hands before donning new gloves and continuing with wound care. The LPN acknowledged this lapse immediately after the procedure. There was also no Enhanced Barrier Precautions (EBP) sign outside the resident's room, as required for residents with certain conditions. Additionally, a CNA provided catheter care to a resident with a history of stroke, hemiplegia, and seizure disorder, but did not wear a gown as required by EBP for high-contact care activities involving indwelling medical devices. The resident's room had signage and gowns available, but the CNA stated that gowns were only used when a resident had an active infection. The facility's policies required the use of PPE, including gowns, for such care activities, but these were not followed during the observed care.