Infection Control and PPE Deficiencies Identified
Penalty
Summary
Multiple deficiencies in infection prevention and control were observed during the survey. Staff failed to perform proper hand hygiene between tasks, such as when a CNA assisted a resident with lunch, then handled used meal trays and other residents, and returned to feeding without sanitizing hands. The Director of Nursing confirmed that hand hygiene is required between tasks, and facility policy specifies hand hygiene before and after direct resident contact and when assisting with meals. Additional observations included staff not performing hand hygiene after doffing PPE and before accessing clean supplies, despite policy requirements for hand hygiene before and after entering transmission-based precaution areas and after handling food. Further deficiencies were noted in the management of medical equipment and infection control practices. A resident's catheter bag was found partially uncovered and in direct contact with the floor, rather than being properly hung from the bed frame. In another instance, respiratory care equipment, including a suction catheter, was not dated or stored correctly, and the tubing was not changed according to the facility's stated schedule. The Infection Preventionist confirmed these practices were not in line with facility policy, which requires suction catheters to be changed every 24 hours. The facility also failed to follow its own protocols for Covid-19 testing and use of personal protective equipment (PPE). Residents who were exposed to Covid-19 positive roommates were not tested within the required timeframes outlined in the facility's policy. Additionally, staff were observed assisting residents on contact precautions without wearing the required PPE, such as gowns, and some staff were unsure of the correct PPE to use. These lapses were confirmed by staff interviews and review of facility policies.