Failure to Follow Infection Control Protocols and Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified multiple failures in the facility's infection prevention and control program, specifically regarding the cleaning of medical equipment and adherence to Enhanced Barrier Precautions (EBP). During medication administration, a licensed nurse used a sphygmomanometer on multiple residents without disinfecting it between uses. Additionally, a nurse applied a nicotine patch, checked oxygen saturation, and changed oxygen tubing for a resident with a known MRSA infection without wearing the required PPE, despite the resident being on EBP. These actions were confirmed by staff present at the time. Further deficiencies were observed during wound care and hygiene activities. A licensed nurse failed to properly dispose of a used gown after wound treatment for a resident on EBP, leaving it on a PPE cart intended for clean items. Another resident with a Foley catheter had the catheter bag touching the floor, and both a nurse aide and a licensed nurse provided hygiene and wound care to this resident without wearing PPE. The facility's policies required the use of PPE and proper cleaning of reusable equipment, but these protocols were not followed as observed.