Infection Control Deficiencies in PPE Use, Housekeeping, and Dining Assistance
Penalty
Summary
Staff failed to consistently follow infection prevention and control protocols in several areas of care. For residents on enhanced barrier precautions (EBP), staff did not remove personal protective equipment (PPE) or perform hand hygiene before exiting resident rooms. In one instance, a nursing assistant exited a resident's room wearing a gown and gloves, cleaned a mechanical lift in the hallway, and only then removed PPE and performed hand hygiene. Another nursing assistant removed gloves but not the gown before leaving a resident's room, carrying the gown down the hallway before being corrected by a nurse. Interviews with staff and the infection preventionist confirmed that PPE should be removed and hand hygiene performed before leaving rooms under EBP, but the facility's policy did not clearly specify this requirement for EBP, only for contact precautions. Housekeeping staff also failed to change gloves and perform hand hygiene between cleaning different resident rooms. One housekeeping aide was observed wearing the same gloves while cleaning two separate rooms, handling cleaning equipment, and touching environmental surfaces without changing gloves or sanitizing hands. The director of environmental services and the infection preventionist both stated that gloves should be changed and hand hygiene performed between rooms to prevent cross-contamination, in accordance with facility policy. During meal assistance, nursing assistants did not perform hand hygiene between assisting multiple residents. Staff were observed using the same hand to feed and wipe the mouths of two different residents without sanitizing hands in between, and in one case, a staff member used their bare hands to assist a resident with eating. Staff interviews confirmed awareness of the need for hand hygiene before and after meal assistance, but there was confusion about procedures when assisting more than one resident at a time. The facility's feeding policy required hand hygiene before and after assisting with eating but did not address hand hygiene between residents when assisting multiple individuals.