Widespread Infection Control Lapses Involving PPE, Hand Hygiene, and Environmental Cleaning
Penalty
Summary
Multiple deficiencies in infection prevention and control practices were observed throughout the facility, involving both staff actions and environmental conditions. In several instances, staff failed to adhere to established protocols for hand hygiene, use of personal protective equipment (PPE), and proper handling of soiled linens. For example, a registered nurse did not perform hand hygiene or don appropriate PPE before handling a resident's PEG tube, and several staff members failed to wear gowns and gloves when providing care to residents on Enhanced Barrier Precautions or Contact Precautions. Additionally, soiled linens were found placed on the floors of residents' rooms by staff, rather than being properly stored in designated containers, as confirmed by both direct observation and staff interviews. Environmental cleaning and disinfection lapses were also documented. In one case, a blood-tinged gauze was found on the floor of a resident's room, and the Director of Nursing confirmed this was inappropriate. Reusable medical equipment, such as a wristlet blood pressure machine, was not disinfected between uses on different residents, and staff failed to clean equipment before returning it to common areas. Enteral syringes were not properly air-dried before being stored, and staff did not consistently perform hand hygiene before or after medication administration or after removing gloves, as required by facility policy and CDC guidelines. Signage and communication regarding isolation and precautionary measures were insufficient. Residents with orders for Enhanced Barrier Precautions or Contact Precautions did not have appropriate signage on their doors, and PPE caddies were not available in relevant hallways. Staff entered and exited rooms of residents on isolation precautions without wearing required PPE, and some residents were unaware of their isolation status. These deficiencies were confirmed through interviews with staff and the Director of Nursing, who acknowledged that proper procedures were not followed in these instances.