Failure to Follow Infection Control Practices During Outbreak and Enhanced Barrier Precautions
Penalty
Summary
Facility staff failed to follow appropriate infection control practices during an outbreak and when residents were on enhanced barrier precautions. Observations revealed that staff did not sanitize items such as name tags, thermometers, and blood pressure devices after they had fallen on the floor or been used in resident care, and these items were placed on surfaces without barriers or cleaning. Staff also failed to use proper personal protective equipment (PPE) consistently, with some entering resident rooms without appropriate PPE during an outbreak period. One resident with multiple diagnoses, including renal insufficiency and chronic respiratory failure, required assistance with activities of daily living and was on enhanced barrier precautions due to a pressure area on the left heel. Staff were observed providing care to this resident without adhering to proper infection control protocols, such as failing to sanitize equipment and not using barriers when placing items in the resident's room. Additionally, staff were seen using the same gloves to handle multiple items and not sanitizing high-touch objects like call lights after they had been on the floor. Interviews with staff and facility leadership confirmed awareness of ongoing infection control issues, including improper mask use and PPE compliance, especially during the outbreak. Facility policy required staff to use gloves and gowns for high-contact care activities and to place barriers under items set down in resident rooms, but these procedures were not consistently followed. The Director of Nursing and Administrator acknowledged continued problems with infection control practices.