Failure to Follow Infection Control Protocols for PPE and Equipment Cleaning
Penalty
Summary
The facility failed to maintain and observe proper infection control measures in two key areas. First, a Restorative Nursing Aide (RNA) did not change isolation gowns between providing direct, high-contact care to two different residents who were both on Enhanced Barrier Precautions (EBP). Specifically, after assisting one resident with range of motion exercises and applying splints, the RNA removed gloves and performed hand hygiene but did not change the isolation gown before repositioning another resident in the same room, both of whom were under EBP due to their medical conditions and physician orders. The RNA acknowledged during an interview that the gown should have been changed between residents to prevent cross-contamination, and both the Infection Preventionist Nurse and the Director of Nursing confirmed that facility policy and infection control protocols require changing gowns and gloves between residents on EBP. Second, the facility did not ensure that the mechanical lift used for transferring residents was sanitized between uses for different residents. Observations showed that after transferring one resident with the mechanical lift, staff did not clean the equipment before using it to transfer another resident. Interviews with the CNA involved, as well as other staff including a Licensed Vocational Nurse, the Director of Staff Development, and the Director of Nursing, confirmed that the mechanical lift should be disinfected after each resident's use to prevent possible cross-contamination. The facility's policy also requires cleaning and disinfecting resident care equipment according to CDC recommendations and OSHA standards. The residents involved in these deficiencies had significant medical conditions, including malnutrition, dysphagia, diabetes, heart failure, contractures, and severe cognitive impairment, which made them dependent on staff for most activities of daily living and placed them at increased risk for infection. The failure to follow established infection control protocols in both the use of personal protective equipment and the cleaning of shared medical equipment created a potential for the transmission of infectious microorganisms among residents and staff.