Failure to Follow Infection Control Protocols for PPE, Hand Hygiene, and Equipment Cleaning
Penalty
Summary
Staff failed to follow infection prevention and control protocols as outlined in the facility's policies on Personal Protective Equipment (PPE) and Hand Hygiene. Two CNAs did not wear gowns or perform hand hygiene before, between, or after glove changes while providing personal care to a resident on Enhanced Barrier Precautions (EBP) due to an indwelling urinary catheter and pressure ulcers. During the care, gloves were changed multiple times without hand hygiene, and clean gloves were donned without sanitizing hands. The CNAs also touched various surfaces in the resident's environment without changing gloves or performing hand hygiene, and left the room without sanitizing their hands. A wound care RN also failed to perform hand hygiene before, between, and after glove changes during a dressing change for another resident. Additionally, two Certified Medication Aides did not sanitize a wrist blood pressure cuff between uses on different residents. Interviews with staff and leadership confirmed that infection control procedures were not followed as per facility policy, despite recent training.