Failure to Adhere to 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 staff members not adhering to established protocols during resident care. Certified Nursing Assistant (CNA) F did not perform hand hygiene before donning gloves, between glove changes, or after providing incontinent care to a female resident with a history of urinary tract infection and severe cognitive impairment. During the care process, the CNA changed gloves without sanitizing hands and handled soiled items before touching clean briefs and padding, further neglecting to wash hands after completing care. Licensed Vocational Nurse (LVN) C did not wear a gown while administering medications via gastrostomy tube to two residents who were on enhanced barrier precautions, as indicated by signage and care plans. Both residents had severe cognitive impairment and required feeding tubes for nutrition. Despite facility policy requiring the use of gloves and gowns during high-contact care for residents with indwelling medical devices, the LVN proceeded with medication administration without donning a gown. The Wound Care Nurse (WCN) J also failed to wear a gown while performing wound care on a male resident with a diabetic foot ulcer who was on enhanced barrier precautions. During the dressing change, the nurse touched the outside edge of the resident's foot and did not change gloves before handling the new dressing. These actions were inconsistent with facility policies on hand hygiene, glove use, and enhanced barrier precautions, as confirmed by staff interviews and policy reviews.