Failure to Follow Infection Control Protocols and Hand Hygiene Standards
Penalty
Summary
Staff failed to follow enhanced barrier precautions (EBP) and use appropriate personal protective equipment (PPE) for residents requiring infection control measures. In one instance, a certified nursing assistant (CNA) removed soiled linen from a resident on EBP without wearing a gown, as required. The CNA was unaware of the resident's EBP status due to the absence of a precautionary sign on the door. The infection control registered nurse later placed the sign, and interviews revealed that staff were expected to verify EBP status through the electronic medical record (EMR) or Kardex system. The resident involved had significant medical conditions, including end-stage renal disease and bacteremia, and a physician order for EBP was present in the EMR prior to the incident. The facility's EBP policy was requested but not provided at the time of the interview. Another deficiency was observed when a resident with a peripherally inserted central catheter (PICC) line was found in physical therapy with the line uncovered and lacking a sterile cap. The director of nursing (DON) acknowledged that the PICC line should have been covered with a sterile cap after each use, as outlined in the facility's policy for PICC line care. The policy specified that an end cap should be placed on the connector to reduce the risk of vascular-associated infections. The resident had a history of osteoarthritis, contracture, pain, and a surgical wound. Additionally, the facility failed to ensure proper hand hygiene during wound care for two residents. The wound care nurse was observed repeatedly removing gloves and donning new ones without performing hand hygiene between glove changes while providing wound care to residents with surgical wounds and pressure ulcers. The DON confirmed that staff would be re-educated on hand hygiene. The facility's hand hygiene policy emphasized the importance of hand washing to prevent healthcare-associated infections. The residents involved had complex medical histories, including recent surgeries, amputations, and pressure ulcers.