Failure to Implement and Maintain Infection Control Practices
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in the use of personal protective equipment (PPE) and hand hygiene during direct resident care. Specifically, an LPN did not wear a gown while administering medications via a feeding tube to a resident who had a physician's order for enhanced barrier precautions. This omission was confirmed by the staff member involved. Additionally, during wound care for another resident with orders for enhanced barrier precautions, an LPN failed to change gloves and perform hand hygiene between removing soiled dressings and applying clean dressings to multiple wound sites, instead using the same contaminated gloves throughout the procedure. This was also acknowledged by the staff member after the observation. Further, a CNA was observed improperly donning a gown, failing to securely tie it, which resulted in the gown falling onto the resident during incontinence care. The CNA admitted to not knowing the requirement to wear a gown for the care provided and to being in a hurry, which led to improper use of PPE. These deficiencies were observed during direct care activities that required enhanced barrier precautions, as indicated by facility policy and CDC guidance posted in the facility. The findings were reviewed and confirmed with facility leadership.