Failure to Follow Infection Control Protocols During Resident Care and Equipment Use
Penalty
Summary
Facility staff failed to adhere to infection prevention and control protocols during resident care and equipment handling. For one resident with a history of cerebrovascular accident, hemiplegia, and neurogenic bladder with an indwelling catheter, staff did not consistently change gloves between tasks. During observed care, a CNA changed gloves after cleaning the resident's peri-area but continued to wear the same gloves while touching the resident's clothing and assisting with other tasks, such as placing a blanket and handing the resident a grabber device. The staff also did not perform hand hygiene immediately after glove removal, as one staff member only applied hand sanitizer after removing gloves and reaching into her uniform pocket. Facility policy required gloves to be replaced when contaminated and for staff to change gloves before and after care or when moving from dirty to clean tasks. Additionally, staff failed to disinfect a mechanical lift between uses. After transferring a resident, a CNA pushed the lift into the hallway without disinfecting it, and another staff member subsequently used the same lift for a different resident without cleaning it. Facility policy stated that equipment should be cleaned and sanitized prior to use in other areas. Interviews with nursing staff and the DON confirmed the expectation that equipment such as mechanical lifts be disinfected before and after use, but this was not observed in practice.