Infection Control Failures in Kitchen, Wound Care, and Isolation Precautions
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices in several areas, as observed during the survey. In the kitchen, the Dietary Manager was seen wearing a hair net that did not fully cover her hair, with long tendrils exposed on both sides of her face, and was also found to have long artificial nails. Both of these actions were in direct violation of the facility's policy, which requires hair nets to fully cover hair and prohibits artificial nails for staff involved in food preparation. The Dietary Manager acknowledged awareness of these requirements during interviews, and the Infection Control Nurse and Director of Nursing confirmed that these practices were not in compliance with CDC recommendations and facility policy. During wound care observations, an LPN failed to use enhanced barrier precautions when assessing a resident's PEG tube site, not donning a gown or gloves before lifting the resident's shirt and breast to access the tube. In another instance, the same LPN and a CNA performed wound care on a different resident with open stage III pressure ulcers. After cleaning bowel material from the resident's buttock region, neither the LPN nor the CNA changed gloves before proceeding with wound care, and the LPN did not perform hand hygiene before donning new gloves. The LPN also reached into her uniform pocket with gloved hands to retrieve a pen, further increasing the risk of cross-contamination during the dressing change. Additionally, a resident on contact precautions for C. difficile was found in a room with a pile of soiled linen, including sheets and blankets with dried red substances, left atop a recliner. The resident reported the linen had been changed that morning, but it had not been removed from the room. The soap dispenser in the room was also found to be non-functional, as the soap bag was not properly engaged, making hand hygiene inaccessible for staff and visitors. The Infection Control Nurse confirmed both the improper storage of soiled linen and the lack of accessible soap in the resident's room.