Infection Control Deficiencies in Hand Hygiene, Glove Use, and Equipment Cleansing
Penalty
Summary
Surveyors identified deficiencies in the facility's infection prevention and control practices during care provided to two residents. For one resident with impaired cognition and a feeding tube, an LPN prepared for tube feeding care by donning a gown and gloves but failed to sanitize hands before applying gloves. Throughout the procedure, the LPN did not change gloves or perform hand hygiene at appropriate intervals, including after handling potentially contaminated items and before applying a new bandage. The LPN only changed gloves once, without hand hygiene between glove changes, and later confirmed that protocol required more frequent handwashing and glove changes, which were not followed. For another resident with multiple medical conditions and a wound on the right upper lateral calf, an RN performed wound care with a nursing student present. The RN followed some hand hygiene steps, such as washing hands and changing gloves at certain points, but failed to sanitize or change gloves after touching the box of dressings and before placing the dressing into the wound bed. Additionally, scissors used to cut the dressing were taken from the student nurse's pocket and were not sanitized before use. The RN acknowledged these lapses during an interview, confirming that the scissors were not cleaned and that gloves were not changed or hands washed before handling the wound dressing. These observations demonstrate that the facility did not consistently ensure proper hand hygiene, glove use, and equipment cleansing during resident care, as required by infection prevention and control protocols. The lapses were directly observed by surveyors and confirmed by staff interviews, affecting two residents reviewed for infection control practices.
Plan Of Correction
F 0880 Lost Creek Nursing and Rehabilitation Center wishes to have this plan of correction submitted as our written allegation of compliance. Preparation and/or execution of this plan of correction does not constitute an admission to nor agreement with, either the existence of, or the scope and severity of, any of the cited deficiencies or conclusions set forth in the statements of deficiencies. This plan is prepared and/or executed to ensure continuing compliance with regulatory requirements. Our alleged date of compliance is 6/27/25. F 0880 Infection Prevention & Control Resident #23 & #9 dressing changes were monitored by the Director of Nursing on 6/12/25, and all infection control standards were followed. An initial audit was conducted on all residents with wounds on 6/13/25 by the Director of Nursing and all infection control standards were met. All clinical staff were educated on infection prevention and control on 6/11/25 by the Director of Nursing, including handwashing and EBP precautions. The Director of Nursing or Designee will conduct an audit with staff 3x a week x 4 weeks to watch dressing changes. Any unusual findings will be forwarded to the QAPI committee for prompt resolution. The Director of Nursing will monitor this area for compliance on an ongoing basis.