Failure to Follow Infection Control Practices and PPE Use
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed by staff, as evidenced by multiple observed deficiencies. One LPN did not perform hand hygiene after touching her face and before providing care, failed to disinfect reusable equipment such as a pulse oximeter and stethoscope before and after use, and did not properly rinse or store a nebulizer mouthpiece after treatment. These actions were in direct violation of the facility's policies regarding hand hygiene and cleaning/disinfection of resident-care items. Additionally, a CNA entered the room of a resident on contact isolation for Clostridium Difficile without wearing required personal protective equipment (PPE), left the door open, and handled the resident's meal tray and personal items without performing hand hygiene after touching potentially contaminated objects. The CNA acknowledged awareness of the contact precautions signage and the requirement to wear gown and gloves, as well as the need to remove PPE and perform hand hygiene before leaving the room. A further deficiency was observed when an RN provided direct care to a resident with a PICC line under enhanced barrier precautions without wearing a gown, contrary to facility policy. The RN stated that a gown and gloves were not necessary for this care, which was later contradicted by the Director of Nursing, who confirmed that staff should wear a gown and gloves when providing direct care to residents with wounds or indwelling medical devices. These failures were confirmed through interviews and policy reviews.