Failure to Follow Infection Control Practices During Resident Care and Meals
Penalty
Summary
Facility staff failed to implement proper infection prevention and control practices during resident care and meal assistance. Two residents with severe cognitive impairment and total dependence on staff for activities of daily living were observed during lunch. A physical therapist assisted one resident with feeding immediately after providing physical therapy, without removing gloves or performing hand hygiene for herself or the resident. Additionally, a certified nursing assistant assisted the other resident with her meal without providing hand hygiene to the resident beforehand. Both staff members acknowledged their lapses, with the physical therapist stating she did not think about hand hygiene and the CNA admitting she forgot to wash the resident's hands before the meal. Further deficiencies were observed regarding the use of enhanced barrier precautions for residents with wounds. One resident with a sacral wound had an enhanced barrier precautions sign posted, indicating the need for gowns and gloves during high-contact care. However, two CNAs provided pericare and hygiene care without donning gowns, later confirming they forgot and could not find gowns nearby. Another resident with multiple wounds received hygiene care and a transfer from his wheelchair to bed by two CNAs who also failed to wear gowns, despite facility policy requiring enhanced barrier precautions for residents with wounds. Facility policies required hand hygiene for staff and residents before meals and the use of gowns and gloves during high-contact care for residents with wounds. These policies were not followed during the observed incidents, as confirmed by staff interviews and direct observation. The failures included both a lack of hand hygiene and improper use of personal protective equipment during care activities for residents at risk.