Widespread Infection Control Lapses During Resident Care and Dining
Penalty
Summary
Staff failed to maintain infection control practices for all residents reviewed, as evidenced by multiple observed lapses. During meal assistance, a CNA wore the same pair of gloves while touching multiple residents and their food items, without performing hand hygiene between contacts. In another instance, staff emptied a resident's catheter bag by placing the graduated container directly on the carpeted floor without a barrier and allowed the catheter drain spout to touch the inside of the container, contrary to facility policy. For another resident, although a barrier was used, the catheter spout repeatedly touched the inside of the graduated container during emptying, and the container was left uncovered on the back of the toilet after use. Additionally, a package of perineal wipes used for one resident was placed on another resident's bedside table after care was completed. Further deficiencies included a staff member providing ostomy care to a resident with a multidrug-resistant organism diagnosis without wearing a protective gown, as required by enhanced barrier precautions. It was discovered that PPE supply bins outside resident rooms were inadequately stocked, with only one out of several bins containing gowns. The DON confirmed expectations for proper hand hygiene, use of barriers, and PPE, which were not met during these observed care activities.