Failure to Follow Infection Prevention and Control Standards
Penalty
Summary
The facility failed to adhere to accepted infection prevention and control standards in several instances involving direct resident care. For one resident, oxygen tubing was observed on the floor for an extended period before being stored in a plastic bag, and the tubing was not immediately replaced after contact with the floor. A nurse initially denied the tubing had touched the floor but later replaced it upon realizing the contamination. In another case, two CNAs provided incontinence care to a resident on Enhanced Barrier Precautions (EBP) without performing hand hygiene prior to resident contact, and one CNA left and re-entered the room without hand hygiene. Both staff members also failed to don the required PPE as indicated by signage and the resident's care plan. Additional deficiencies included a nurse improperly donning PPE, leaving her arms exposed while providing enteral feeding to a resident on EBP, and expressing confusion about the correct procedure. In a separate incident, a nurse exited a resident's room during a dressing change while wearing gloves, touched the doorknob, and resumed the procedure without changing gloves or performing hand hygiene. These actions were acknowledged by the staff involved, who admitted to not following proper infection control protocols.