Multiple Lapses in Infection Control Practices
Penalty
Summary
Surveyors observed multiple failures in infection prevention and control practices within the facility. Two used diapers were found placed on top of a resident's cabinet drawer instead of being disposed of in a trash bin, as confirmed by both the LVN and the Infection Preventionist. This action was contrary to facility policy and was acknowledged by staff as a source of potential contamination. Additionally, a direct care staff member was observed wearing long artificial fingernails while providing resident care. The staff member admitted to having acrylic nails that extended significantly beyond the fingertip, and both the Infection Preventionist and facility policy indicated that such nails are prohibited for direct care staff due to the risk of harboring pathogens and causing skin injury to residents. Further deficiencies were identified in the use of personal protective equipment (PPE) and hand hygiene. A Certified Restorative Nursing Assistant (CRNA) was observed providing care to a resident with an active MRSA wound infection without donning the required gown and gloves, despite clear signage and physician orders for contact precautions and enhanced barrier precautions. The CRNA also failed to clean and disinfect the Hoyer lift after use with the same resident and did not perform hand hygiene after providing care. These lapses were acknowledged by the CRNA and confirmed by the Infection Preventionist as violations of facility policy and CDC recommendations for infection control. Another incident involved a Certified Nursing Assistant (CNA) who was observed providing care to a resident while exhibiting symptoms of a respiratory infection, including sniffling and a runny nose, without wearing a mask. The CNA admitted to feeling ill and not reporting her symptoms to a supervisor, as required by facility policy. The resident receiving care had chronic obstructive pulmonary disease, diabetes, and was dependent on supplemental oxygen, making her particularly vulnerable. Facility leadership confirmed that staff are required to report illness and wear masks if symptomatic, but these procedures were not followed in this instance.