Infection Control Lapses in PPE Use, Equipment Disinfection, and Respiratory Care
Penalty
Summary
The facility failed to maintain effective infection prevention and control measures in several instances, as observed and documented by surveyors. In one case, enhanced barrier precautions (EBP) signage was incorrectly assigned to the wrong resident's bed, leading to confusion among staff about which resident required EBP. A certified nursing assistant (CNA) entered a room with an EBP sign without wearing the required personal protective equipment (PPE) and assisted a resident with incontinence care, only using gloves instead of both gown and gloves. The infection preventionist (IP) later clarified that the EBP sign was misplaced and should have been for a different resident, but this error was not corrected in a timely manner, resulting in improper infection control practices. In another instance, nursing staff did not implement EBP for a resident who had colonized bacteria and a skin tear requiring dressing. Despite the EBP sign being posted and the care plan indicating the need for gown and glove use during high-contact care, two CNAs performed an incontinence brief change without wearing gowns. One CNA was unaware of the EBP sign, and both confirmed that proper PPE should have been used. Additionally, the facility failed to enforce isolation precautions for COVID-19 positive residents, as doors to rooms with special droplet/contact precautions were left open, contrary to facility policy and posted signage instructing that doors remain closed. Further deficiencies included improper disinfection of blood pressure (BP) cuffs and machines, with staff using hand sanitizer wipes or alcohol prep pads instead of EPA-registered disinfectants as required by facility policy. There were also lapses in the handling of respiratory equipment: a resident's nebulizer mask was found unlabeled and not stored in a bag, and another resident's oxygen humidifier was left open and not replaced as ordered. These failures were confirmed through staff interviews and record reviews, with staff acknowledging the lapses and referencing facility policies that were not followed.