Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple instances of staff not following proper infection control protocols during resident care. In one case, a CNA provided incontinent care to a female resident with dementia and congestive heart failure without changing gloves or performing hand hygiene between cleaning the resident's front and back areas. The CNA then touched clean items and assisted the resident to her wheelchair while still wearing the same contaminated gloves, only removing them and washing hands after completing all care tasks. Interviews confirmed that the CNA was aware of the correct procedures but did not follow them during the observed care. In another instance, an LVN administered IV medication to a male resident with sepsis and cellulitis, who was on enhanced barrier precautions (EBP), without donning a gown as required by the resident's care plan and facility policy. The LVN performed hand hygiene and wore gloves but omitted the gown, later stating that nervousness caused her to forget this step. The resident's care plan and EBP signage in the room clearly indicated the need for both gloves and gown during high-contact care activities, including IV medication administration. Additional deficiencies were observed with another male resident with quadriplegia and a feeding tube, also on EBP. An LVN administered medications via the resident's gastrostomy tube without wearing a gown, despite the presence of PPE supplies and EBP signage in the room. Furthermore, two CNAs provided personal care, including bathing, to the same resident without donning gowns. Both staff members acknowledged their training on PPE use and the importance of infection control, but failed to comply with established protocols during the observed care activities.