Failure to Adhere to Infection Control Practices and Hand Hygiene
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in the use of personal protective equipment (PPE) and hand hygiene for four residents. One resident with a history of MRSA and severe cognitive impairment was on contact precautions, but staff did not consistently wear the required gown and gloves when providing care. Observations showed that staff entered the resident's room and performed personal care and medication application without donning the appropriate PPE, despite signage indicating contact precautions. Staff interviews revealed confusion and inconsistent understanding regarding when to use gowns and gloves for contact precautions. Hand hygiene practices were also deficient during catheter care and medication administration. In one instance, a staff member providing catheter care to a resident on Enhanced Barrier Precautions failed to perform hand hygiene after removing gloves and before donning new gloves, as well as after completing care. The staff member was unaware of the requirement to use hand hygiene immediately after glove removal and before touching other surfaces. This failure was observed during the process of assisting the resident with toileting and catheter care. Additionally, during medication administration, a nurse was observed preparing and administering medications to two residents without performing hand hygiene at any point between residents or after handling medication cups and other surfaces. The nurse acknowledged forgetting to perform hand hygiene and was reminded of the expectation to do so before and after entering residents' rooms and after providing care. These observed failures demonstrate a lack of adherence to established infection control policies and procedures.