Failure to Follow Infection Control Protocols for Precautions and Equipment
Penalty
Summary
Facility staff failed to adhere to established infection prevention and control protocols for two residents. For one resident colonized with a multi-drug resistant organism (CRE), both Enhanced Barrier Precautions and Contact Precautions were ordered and signage indicated the need for surgical masks, eye protection, gowns, and gloves during care. However, during a transfer using a hoyer lift, two staff members were observed wearing only gloves, despite acknowledging that gowns were also required. This was confirmed in interviews, where staff admitted to not following the full PPE requirements as outlined in facility policy and physician orders. In a separate incident, another resident with multiple pressure wounds and a physician order for a pressure-reducing air mattress was observed to have an air mattress placed directly on the floor without any protective covering. The mattress was being inflated in preparation for use, but was left exposed to potential contamination from dirt and debris. A licensed nurse confirmed the mattress was on the floor and uncovered at the time of observation.