Failure to Follow Infection Control Practices During Resident Care
Penalty
Summary
Multiple staff members failed to adhere to standard infection prevention and control practices during direct care of several residents. Certified Nursing Assistant 4 (CNA 4) did not change gloves or perform hand hygiene after providing incontinence care to two residents, subsequently touching their bed sheets, bed remotes, and bodies with contaminated gloves. CNA 4 acknowledged during interview that gloves should have been changed and hand hygiene performed to prevent the spread of infection. The Infection Preventionist Nurse (IPN) confirmed that gloves soiled with urine and feces must be removed and hand hygiene performed before touching other surfaces or the resident. The Respiratory Therapist Director (RTD) was observed providing tracheostomy care to a resident and, without changing gloves or performing hand hygiene, touched the resident's personal items such as a cell phone and television remote. RTD then used the same gloves to prepare a sterile drape and handle a speaking valve, actions which he admitted could spread infection to the resident. The IPN stated that gloves should have been changed and hand hygiene performed after contact with personal items to prevent transmission of microorganisms to the tracheostomy area. Additional deficiencies included CNA 5 exiting a resident's room while still wearing PPE and handling dirty linen in the hallway, which she acknowledged was inappropriate due to the risk of spreading infection. Licensed Vocational Nurse 4 (LVN 4) was observed on two occasions failing to change gloves and perform hand hygiene between tasks during medication administration and gastrostomy tube care for two residents. LVN 4 admitted that gloves should have been changed to reduce the risk of introducing bacteria. The facility's policies and procedures require glove changes and hand hygiene after contact with blood, body fluids, and environmental surfaces, and specify that gloves are single-use only.