Deficient Infection Control Practices and Improper PPE Use
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices as outlined in its own policies and procedures. Certified Nurse Assistant 1 (CNA 1) was observed exiting a resident's room after providing peri-care while still wearing contaminated gloves and used those gloves to close the resident's door. CNA 1 acknowledged during an interview that gloves should have been removed and hand hygiene performed before leaving the room. The Infection Preventionist Nurse (IPN) and Director of Nursing (DON) both confirmed that this action was not in accordance with facility policy and could contribute to the spread of infection, especially during an ongoing COVID-19 outbreak in the facility. The facility's policies require gloves to be discarded in the room where care is provided and for staff to perform hand hygiene before and after glove removal and upon exiting a resident's room. Additionally, there were failures related to the use of personal protective equipment (PPE) in rooms under novel respiratory precautions. CNA 1 was observed entering an isolation room without wearing a required face shield, despite signage and facility policy indicating that a face shield, N-95 mask, gown, and gloves must be worn before entry. CNA 1 admitted knowledge of the requirement but did not comply. In another instance, a family member (FM 2) was observed entering a resident's room with an N-95 mask worn incorrectly, with the metallic strip under the chin instead of over the nose, which was confirmed by a Licensed Vocational Nurse (LVN 2) to be improper and not in line with the facility's instructions for proper fit and use. The facility's policies on management of COVID-19 and transmission-based precautions require strict adherence to PPE protocols, including correct donning and doffing procedures and proper use of equipment to prevent the spread of communicable diseases. Observations and interviews confirmed that staff and visitors did not consistently follow these protocols, resulting in deficiencies in infection control practices.