Failure to Follow Infection Control Practices for PPE and Equipment Disinfection
Penalty
Summary
Two deficiencies in infection prevention and control practices were identified during observations, interviews, and record reviews. In the first instance, two certified nursing assistants (CNAs) provided care to a resident with a femur fracture and Alzheimer's Disease who was under Enhanced Barrier Precautions (EBP) due to a leg dressing. Despite a posted EBP sign instructing staff to wear gloves and gowns for high-contact care activities, both CNAs repositioned the resident in bed without donning the required personal protective equipment (PPE). One CNA stated that staff did not need to wear a gown or gloves when repositioning a resident in bed, which was contradicted by the facility's Infection Preventionist and CDC guidelines, both of which classify moving a resident in bed as high-contact care requiring PPE. In the second instance, a registered nurse (RN) used a reusable blood pressure machine and cuff on two different residents without cleaning or disinfecting the equipment between uses. The RN acknowledged that the equipment should have been cleaned and disinfected after each use, and the Infection Preventionist confirmed that failure to do so could result in microbe transmission between residents. The facility's policy also required reusable items to be cleaned and disinfected between residents, but this protocol was not followed during the observed care.