Infection Control Deficiencies: Hand Hygiene, PPE, and Equipment Cleaning
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's infection prevention and control practices, specifically related to hand hygiene, use of personal protective equipment (PPE), and cleaning/disinfection of shared equipment. Staff were observed failing to perform hand hygiene at critical points, such as before donning gloves, after removing soiled gloves, and between resident contacts. In several instances, staff did not provide complete perineal care to residents who were incontinent, and failed to change gloves or perform hand hygiene when required by facility policy. For example, during care for a resident with cancer, dementia, and incontinence, staff did not wash hands before or after glove use, did not provide full perineal hygiene, and did not disinfect the mechanical lift after use. The report also documents failures in the use of Enhanced Barrier Precautions (EBP) for residents with a history of multidrug-resistant organisms (MDROs), wounds, or indwelling medical devices. Staff did not consistently wear required PPE, such as gowns and gloves, during high-contact care activities for residents on EBP. In one case, a medication aide assisted a resident with a history of MRSA with toileting and perineal care without wearing a gown and failed to change gloves or perform hand hygiene at appropriate intervals. Another instance involved a nurse not removing PPE before exiting a resident's room and placing potentially contaminated items on the medication cart without a barrier or cleaning. Additionally, the facility failed to clean and disinfect mechanical lifts between resident uses, as required by policy. Multiple staff members confirmed during interviews that lifts were not cleaned after transferring residents, including those with cognitive impairments and those dependent on staff for mobility. These lapses in infection control practices were observed across several residents and staff, indicating a systemic failure to adhere to established protocols designed to prevent cross-contamination and the spread of infection within the facility.