Failure to Adhere to Infection Control Practices and Sanitary Storage of Equipment
Penalty
Summary
Staff failed to follow infection control practices related to Enhanced Barrier Precautions (EBP) and the sanitary storage of ice scoops. Certified Nursing Assistants (CNAs) entered a resident's room, who was on EBP due to conditions including vertebral fractures and muscle weakness, without performing hand hygiene or donning the required personal protective equipment (PPE) such as gowns and gloves. The CNAs donned gloves only after entering the room and did not perform hand hygiene after removing gloves and exiting. Both CNAs acknowledged awareness of the EBP signage and requirements but stated they forgot to follow the protocols. Additionally, a Certified Phlebotomy Technician (CPT) drew blood from a resident on EBP without wearing a gown and placed a supply container directly on the resident's bed, later moving it to a cart without disinfecting it. The CPT was unaware that drawing blood was considered a high-contact activity requiring full PPE, as clarified by the Infection Preventionist (IP). Observations also revealed that ice scoops at two different ice/water stations were stored in uncovered metal containers that lacked drainage, resulting in the scoops resting in standing water. Both the Treatment Licensed Nurse (Tx LN) and the Registered Dietitian (RD) confirmed that the scoops were considered contaminated due to their storage conditions and the risk of cross contamination. The facility's policies required that ice scoops be covered and stored in containers with drainage to prevent contamination, but these procedures were not followed. Interviews with the Director of Nursing (DON), Infection Preventionist, and other staff confirmed that the observed practices did not align with facility policies on hand hygiene, PPE use, and environmental cleaning. The DON and other staff acknowledged the expectations for proper infection control measures, including donning PPE before entering EBP rooms and ensuring sanitary storage of equipment, but these were not adhered to during the observed incidents.