Failure to Implement Infection Control and Hand Hygiene Practices During Resident Care
Penalty
Summary
Staff failed to implement appropriate infection prevention and control practices during care for two residents with indwelling medical devices and wounds. For one resident with an indwelling catheter, a CNA donned gown and gloves without performing hand hygiene, placed a urine graduate on a barrier on the floor, and emptied the catheter drainage bag without cleaning the drainage port beforehand. The drainage port was only cleansed with an alcohol wipe after the bag was emptied, and the CNA left the room without performing hand hygiene. Both the Infection Preventionist and the Director of Nursing confirmed that hand hygiene should be completed and Enhanced Barrier Precautions (EBP) should be used at appropriate times during catheter and wound care, as outlined in facility policy. Another resident with multiple chronic conditions, including venous and arterial ulcers, required frequent wound care to both lower extremities. During wound care, an LPN demonstrated inconsistent hand hygiene, such as removing gloves and donning new ones without hand hygiene, and did not always use a gown when applying dressings to the buttocks. The LPN also failed to maintain a clean and dirty environment, placing opened bandages on her lap and under her arm, and continued to use supplies that had fallen on the floor without changing gloves or performing hand hygiene. Dressings were not dated, and the LPN was observed to request assistance from the Infection Preventionist, who had to don PPE to assist. Facility policies required adherence to the 4 Moments of Hand Hygiene and the use of EBP for residents with indwelling devices or wounds, including the use of gloves and gowns during high-contact care activities. Observations and interviews revealed that staff did not consistently follow these protocols, leading to lapses in infection control practices for both residents. The Director of Nursing and Infection Preventionist acknowledged these deficiencies, noting failures in hand hygiene, PPE use, and maintenance of clean and dirty technique during resident care.