Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
Staff failed to properly implement infection prevention and control protocols during care of a resident. Two staff members, a QMA and an RN, did not tie their PPE gowns at the waist before entering the resident's room, contrary to facility policy. The QMA, while wearing gloves, performed multiple tasks including oral care, handling a catheter drainage system, operating a mechanical lift, removing hearing aids, assisting with repositioning, handling the resident's oxygen line, removing the resident's pants, and handling cleaning wipes, all without changing gloves or performing hand hygiene between tasks. The QMA only removed her gloves after completing these tasks and acknowledged not changing gloves between them. The RN was observed cleaning the resident after a bowel movement, removing and discarding gloves, and then putting on a new pair of gloves without performing hand hygiene in between. The RN then performed wound care, cleaning the wound area in a manner inconsistent with proper technique, as confirmed by both the RN and the Director of Nursing during interviews. Facility policies reviewed indicated that gowns should be fastened at the neck and waist and that hand hygiene should be performed after removing gloves. These lapses were observed and confirmed through staff interviews and review of facility policies.