Failure to Follow Infection Control Procedures for Residents on Enhanced Barrier Precautions and During Meal Service
Penalty
Summary
Staff failed to adhere to infection control procedures for multiple residents requiring enhanced barrier precautions (EBP) and for a resident with a suprapubic catheter. In one instance, two certified nurse aides (CNAs) donned gowns and gloves before entering the room of a resident on EBP and performed catheter care. However, after completing personal care, one CNA continued to wear the same gloves while handling the resident's clothing, opening doors, and retrieving supplies, only removing the gloves and performing hand hygiene after these tasks. This sequence did not follow proper glove-changing protocols between different care activities, as confirmed by administrative staff. In another case, two CNAs provided care to a resident with a urinary catheter and cognitive impairment who was also on EBP. After providing perineal and catheter care, one CNA left the resident's room wearing her gown, only removing it after reaching the soiled utility area outside the room. This action was inconsistent with the facility's EBP policy, which requires removal of gowns before exiting the resident's room. The resident's medical record indicated a history of urinary tract infections and dependence on staff for toileting and catheter care. Additionally, a dietary staff member placed a plastic tub containing dirty dishes on a table where residents were still eating, and continued to collect dirty dishes from other tables into the same tub. This practice was observed and later confirmed by administrative and dietary management staff to be inappropriate, as it did not align with infection prevention protocols outlined in the facility's policies.