Infection Control Lapses in Wound Care, Peri-Care, Surveillance, and Respiratory Equipment Handling
Penalty
Summary
Staff failed to follow infection prevention and control protocols in several instances. An LPN applied mupirocin ointment to the back of a resident's head without wearing gloves, despite facility policy requiring standard precautions for wound care. The resident had an intact cognitive status, as indicated by a BIMS score of 15. The LPN stated they did not use gloves because they preferred frequent handwashing over using alcohol gel. During peri-care for a resident with severe cognitive impairment and total incontinence, two CNAs did not change gloves after cleaning the resident and before handling clean linen. One CNA placed soiled linen on the floor and did not perform hand hygiene after removing gloves, subsequently entering another resident's room and assisting with a shower without hand hygiene. Facility policy required glove changes and hand hygiene at specific points during care, which were not followed. The IP acknowledged these lapses and noted that soiled linen should not be placed on the floor. The facility also failed to identify infection trends over three months, despite having infection control logs showing multiple cases of skin infections and UTIs. The IP admitted to not identifying trends as required by policy. Additionally, respiratory equipment for a resident was not properly bagged, labeled, or dated, with a nebulizer mouthpiece left unbagged and moist on a bedside table and oxygen tubing lacking a date. Staff confirmed that infection control policies for respiratory equipment were not followed in these instances.