Failure to Follow Infection Control Practices for PPE and Hand Hygiene
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed, as evidenced by multiple observations of a CNA reusing face shields between resident rooms without disinfecting them. The CNA donned and doffed PPE, including a face shield, when entering and exiting rooms on droplet isolation, but placed the used face shield back into the over-the-door organizer without cleaning it. The CNA also reused the same face shield for subsequent room entries without disinfecting it, despite bleach wipes being available for this purpose. Facility signage and policy required that reusable PPE such as face shields be disinfected or placed in a designated receptacle for reprocessing, but this was not followed. Additionally, the same CNA was observed failing to perform hand hygiene before and after entering resident rooms, including a COVID isolation room, and after removing PPE. The CNA delivered breakfast trays to residents without washing hands or using alcohol-based hand sanitizer, contrary to posted signage and facility policy, which required hand hygiene after PPE removal and between resident contacts. These lapses in infection control practices had the potential to affect 38 residents residing on the 100 and 200 hallways.