Widespread Infection Control Failures During Norovirus Outbreak and Routine Care
Penalty
Summary
Multiple deficiencies in infection prevention and control were identified, including the failure to implement Enhanced Barrier Precautions (EBP) for a resident with chronic stage two pressure ulcers. Staff entered the resident's room and provided direct wound care without donning required personal protective equipment such as gowns, and there was no EBP signage or PPE cart at the room entrance. The Assistant Director of Nursing confirmed a misunderstanding of EBP requirements, believing they only applied to open wounds and indwelling devices, despite the facility's policy stating that chronic wounds, including pressure ulcers, require EBP. Hand hygiene and equipment disinfection protocols were not followed during blood glucose monitoring. A registered nurse failed to perform hand hygiene before and after checking a resident's blood sugar and did not disinfect the shared blood glucose meter after use. The nurse confirmed the lapse and noted the absence of disinfectant wipes in the medication cart, contrary to facility policy requiring cleaning and sanitizing of medical devices between uses and adherence to hand hygiene protocols. During a norovirus outbreak, the facility failed to restrict symptomatic staff from work, did not implement timely isolation and contact precautions, and did not post outbreak signage at facility entrances. Symptomatic staff, including dietary aides and CNAs, continued to work or returned before being symptom-free for the required period. Staff were observed entering isolation rooms without appropriate PPE, and hand hygiene was not consistently performed after resident care or handling contaminated items. The outbreak resulted in widespread illness among residents and staff, and one resident contracted norovirus and subsequently died from acute renal failure related to viral gastroenteritis. Additionally, the facility failed to monitor and document hot water temperatures and flush water lines as required to prevent Legionella, and did not ensure proper use of PPE and cleaning protocols for residents on contact precautions.