Failure to Adhere to Infection Prevention and Control Protocols
Penalty
Summary
Staff failed to consistently use appropriate personal protective equipment (PPE) and perform hand hygiene as required by facility policy and procedure, particularly when providing care to residents on enhanced barrier precautions (EBP) and during medication administration. Multiple observations documented staff entering resident rooms, including those with EBP signage and available PPE, without donning gowns or performing hand hygiene. Staff were seen donning gloves without prior hand hygiene, providing direct care such as flushing midline catheters, administering medications, and performing incontinence care, then removing gloves and exiting rooms without hand hygiene. In several cases, staff proceeded to handle medication carts, computers, and other residents without sanitizing their hands between tasks. Residents involved included those with significant infection risks, such as individuals with indwelling medical devices (e.g., midline catheters, artificial joints, feeding tubes) and those requiring respiratory care equipment. For example, one resident with a right upper arm midline catheter and a history of joint replacement and surgical wound complications was cared for by staff who did not follow EBP protocols or hand hygiene requirements. Another resident's oxygen concentrator humidification bottle was observed sitting on the floor, contrary to infection prevention standards. Staff interviews revealed a lack of understanding or recall of EBP requirements and hand hygiene protocols, with several staff acknowledging lapses or uncertainty about the correct procedures. The facility's policies on EBP and hand hygiene, last revised in August 2025, require the use of gowns and gloves for high-contact care activities and mandate hand hygiene before and after resident contact, after glove removal, and before handling medications or invasive devices. Despite these policies, repeated failures were observed across multiple staff members and shifts, including LPNs and CNAs, during medication administration, vital sign collection, respiratory care, and meal assistance. These deficiencies were confirmed through direct observation, staff interviews, and review of facility policies.