Failure to Implement Infection Control and Enhanced Barrier Precautions
Penalty
Summary
Staff failed to implement infection prevention and control measures in several instances involving residents with indwelling medical devices. One resident, who was totally dependent on staff and had an indwelling urinary catheter, was observed with the catheter tubing and urinary bag resting on the floor next to the bed, despite the bag being covered with a privacy bag. The Interim DON confirmed that no part of the Foley catheter system should be on the floor. Additionally, staff did not consistently perform hand hygiene between glove changes during resident care, as observed during medication administration and dressing changes. Facility policy requires hand hygiene before donning gloves and after removing them, but this was not followed by staff in multiple instances. Further observations revealed that staff did not adhere to Enhanced Barrier Precautions (EBP) when providing care to residents with gastrostomy tubes. In two separate cases, staff administered medications or flushed feeding tubes without wearing the required gown, and in one case, only gloves and a mask were used. The facility's policy mandates the use of gown and gloves during high-contact care activities for residents with indwelling medical devices, including gastrostomy tubes. The Infection Preventionist confirmed that staff are trained to follow these protocols, but the observed practices did not align with facility policy.