Failure to Follow Infection Control Standards During High-Contact Care Activities
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices for several residents requiring enhanced barrier precautions (EBP) due to indwelling medical devices or wounds. In several instances, nursing staff performed high-contact care activities such as flushing Foley catheters and changing wound dressings without donning required gowns, despite clear facility policies and visible indicators (red dot stickers and PPE supplies) at resident rooms. Additionally, staff failed to follow proper glove use and hand hygiene protocols, such as not removing gloves or performing hand hygiene after handling soiled dressings or before obtaining clean supplies, and not changing gloves or performing hand hygiene between different care tasks. Certified nurse aides (CNAs) were observed providing perineal care and assisting with transfers without adhering to hand hygiene requirements. For example, after removing gloves post-perineal care, CNAs did not perform hand hygiene before proceeding to other tasks like adjusting clothing, handling personal items, or bagging linens. In one case, a CNA used soiled gloves to retrieve and apply barrier cream from a resident's nightstand, then continued with other tasks without proper glove change or hand hygiene. These lapses occurred despite the facility's policies and professional standards requiring hand hygiene after glove removal and between resident care activities. Further deficiencies were noted in the technique of perineal care for male residents. Staff failed to retract the foreskin during cleaning, as required to remove smegma and reduce bacterial growth, which was later observed by a nurse during catheterization preparation. Interviews with administrative nursing staff confirmed that the observed practices did not meet the facility's expectations for infection control during high-contact care activities, including the use of appropriate PPE and adherence to hand hygiene protocols.