Infection Control Lapses in Equipment Disinfection and PPE Use
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in infection control practices observed among staff caring for three residents. During a morning medication pass, a medication aide did not disinfect a reusable blood pressure cuff before or after use between two residents, despite being aware of the requirement to do so. The aide admitted to forgetting this step due to nervousness and being new to the role. The Director of Nursing confirmed that staff had been trained on this expectation and that competency checks were in place. In another instance, two certified nursing assistants (CNAs) did not perform proper hand hygiene when changing gloves during morning care for a resident who was on Enhanced Barrier Precautions (EBP) due to an indwelling Foley catheter. The CNAs were observed changing gloves multiple times without sanitizing their hands, and one CNA did not wear a gown as required for EBP. Both CNAs handled the resident’s personal care, including peri-care and device care, without adhering to the facility’s infection control protocols for hand hygiene and personal protective equipment (PPE). Interviews with the involved staff revealed gaps in knowledge and adherence to infection control procedures, with one CNA stating she forgot to wear a gown and did not carry hand sanitizer, while the other was unaware of the need for a gown for residents on EBP. The facility’s policies required routine cleaning and disinfection of shared equipment, proper use of PPE, and hand hygiene before and after glove use, especially for residents on EBP. These failures were observed despite signage and supplies being available and staff having received training on infection control and EBP requirements.