Failure to Maintain Infection Control During Meal Delivery, Foley Catheter Care, and Infection Surveillance
Penalty
Summary
Staff failed to maintain infection prevention and control protocols during the delivery of meal trays to residents on Enhanced Barrier Precautions (EBP). Observations showed a CNA repeatedly entered and exited multiple EBP rooms without sanitizing her hands before or after contact, despite clear signage instructing all staff to perform hand hygiene. The CNA also handled items such as coffee cups and bedside tables without performing hand hygiene, and interviews confirmed a misunderstanding or disregard of the facility's EBP and hand hygiene policies during meal tray delivery. During Foley catheter care for a resident with a history of osteomyelitis, acute kidney failure, and cognitive communication deficit, a registered nurse performed the procedure without donning a gown as required by EBP protocols. The nurse also failed to sanitize her hands between glove changes throughout the care process, despite the presence of an EBP sign and available PPE outside the resident's room. The nurse acknowledged these lapses, attributing them to forgetting the resident's EBP status and not having alcohol-based hand rub available in the room. Facility leadership confirmed that the expected practice was not followed during this high-contact care activity. The facility's infection prevention and control program was also found deficient in tracking and trending infections. Infection control logs for several months were not completed in real time, and there was no evidence of systematic trending or analysis of infection data as required by facility policy. Interviews with the Assistant Director of Nursing and the Regional Clinical Director confirmed that infection surveillance was not being conducted according to policy, and that the lack of tracking and trending could contribute to the spread of infection.