Infection Control Failures in Hand Hygiene, EBP, Equipment Sanitization, and Food Service
Penalty
Summary
The facility failed to implement and maintain effective infection prevention and control practices in several key areas, as evidenced by direct observations, interviews, and record reviews. Staff did not consistently follow Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices, wounds, or multidrug-resistant organism (MDRO) colonization or infection. Multiple residents who required EBP, including those with urinary catheters, central lines, and feeding tubes, did not have appropriate signage posted to alert staff to don personal protective equipment (PPE) before providing high-contact care. Staff were observed performing resident care activities, such as medication administration and tube feeding, without wearing gowns or performing hand hygiene as required by EBP protocols. Hand hygiene practices were not followed during medication administration and wound care. Staff were observed donning gloves without prior hand hygiene, failing to change gloves or sanitize hands between tasks, and touching non-sterile items before proceeding with sterile procedures. For example, during wound care and PICC line medication administration for a resident, staff did not remove gloves or perform hand hygiene after handling potentially contaminated surfaces and before proceeding with invasive procedures. Staff interviews confirmed awareness of proper protocols, but these were not consistently practiced during observed care. Additional deficiencies included failure to sanitize shared equipment, such as mechanical lifts, between resident uses, and improper food service practices during meal assistance. Staff were observed delivering meal trays, adjusting residents, and assisting with feeding without performing hand hygiene between tasks. One staff member was seen blowing on a resident's food to cool it, which was acknowledged by staff and administration as an infection control issue. Furthermore, a resident's PICC line dressing was not changed within the required timeframe, resulting in a nine-day interval between changes, contrary to provider orders and care plan instructions.