Infection Control Deficiencies: PPE Use, Hand Hygiene, and Precaution Signage
Penalty
Summary
Multiple deficiencies in infection prevention and control were identified during observations and record reviews for several residents. Staff failed to consistently wear required personal protective equipment (PPE), such as gowns and gloves, when providing high-contact care to residents on Enhanced Barrier Precautions (EBP) or contact precautions. In one instance, a nurse aide provided incontinent care to a resident with a gastrostomy tube without donning an isolation gown, despite clear signage and available supplies. Additionally, signage for transmission-based precautions was not always correctly posted, as seen with a resident on contact precautions for Clostridium difficile, where only EBP signage was displayed instead of the required contact precautions signage. Hand hygiene practices were not followed according to facility policy and standard precautions. During wound care and dressing changes for residents with pressure ulcers, staff failed to perform hand hygiene before donning gloves, between glove changes, and after glove removal. In several cases, staff reapplied gloves multiple times without hand hygiene, and in one instance, left the resident's room without performing hand hygiene. These lapses were acknowledged by the staff involved and confirmed by interviews with the infection preventionist and director of nursing, who stated that hand hygiene should have been performed at each required step. Improper handling of soiled linen was also observed. A nurse aide was seen carrying visibly soiled linen and a soiled brief in the hallway, then removing gloves and accessing clean linen without performing hand hygiene. Facility policy requires hand hygiene after handling soiled materials and before handling clean items. These failures to adhere to infection control protocols were observed across multiple staff members and resident care situations, as documented in the facility's own policies and confirmed through staff interviews.