Infection Control Program Deficiencies: Hand Hygiene, PPE, and Personal Care Item Storage
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in infection control practices. Staff did not consistently perform hand hygiene before and after resident care, with three out of three staff observed failing to do so. In several resident rooms, personal care items such as basins, urinals, and denture cups were found unlabeled, unbagged, and improperly stored, including on the floor or without lids. Staff interviews confirmed that these items should have been labeled, bagged, and stored appropriately to prevent contamination. During medication administration, a nurse was observed placing multiple medication containers directly on a resident's bed without a barrier and then returning the containers to the medication cart without cleaning them, creating a risk of cross-contamination. The same nurse was also seen placing a hand-held inhaler from their pocket into the medication cart. The DON confirmed that staff are expected to use barriers to prevent cross-contamination during medication passes. Additionally, staff were observed not wearing required surgical masks properly in resident care areas, with some staff wearing masks below their noses or not at all, despite facility policy requiring mask use in these areas. Further observations revealed that staff did not perform hand hygiene between glove changes or between clean and dirty care tasks, particularly during catheter and enteral feeding care. In one instance, a CNA changed gloves without hand hygiene while providing catheter care, and another staff member entered a resident's room to provide enteral feeding care without performing hand hygiene or wearing their mask correctly. Staff interviews confirmed that hand hygiene was expected at key points during resident care, but these practices were not consistently followed.