Infection Control Lapses in Staff Practices and Policy Implementation
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in staff practices and policy implementation. Certified Nursing Assistants (CNAs) were observed providing incontinence and catheter care without adhering to proper infection control protocols. One CNA used the same cleansing wipe to clean both the peri area and catheter tubing of a resident with a urinary catheter, without changing gloves or performing hand hygiene, even after contact with stool. Another CNA provided catheter care using a single washcloth for both the penis and catheter tubing, again without changing gloves or performing hand hygiene. Review of competency checklists revealed incomplete documentation and a lack of observed return demonstrations for these staff members, with one CNA stating she had not received additional training at the current location and the Infection Preventionist confirming that visual skills check-offs were not routinely performed or documented. Additional deficiencies were observed regarding staff adherence to facility policies on personal appearance and use of personal protective equipment (PPE). One LPN was observed with artificial fingernails extending past the fingertips, in violation of CDC recommendations and facility expectations, though the employee handbook did not explicitly prohibit artificial nails. Another staff member was observed with long, untethered braids that came into contact with a resident and bed linens during care, despite the expectation for staff to be neat and well-groomed. The facility's policy on employee appearance was found to be vague and did not specifically address artificial nails or hair containment. Further, staff failed to implement contact isolation precautions as required. Two CNAs entered a contact isolation room without donning PPE or gloves and did not perform hand hygiene before entering. One CNA stated he was unaware of the resident's contact precautions, while the other admitted to not paying attention to the signage. Interviews with the Infection Preventionist and DON revealed that while infection control is discussed during orientation, there is no structured or documented observation of staff practices, and compliance rates are not tracked. These failures collectively demonstrate a lack of consistent implementation and monitoring of infection prevention and control measures.