Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
Staff failed to adhere to infection prevention and control protocols in several instances. During wound care for a resident with an unstageable pressure ulcer and a stage 3 pressure ulcer, the wound care nurse did not don personal protective equipment (PPE) as required for Enhanced Barrier Precautions (EBP). Both the nurse and the Director of Nursing confirmed that PPE should have been used prior to providing wound care to this resident, who was at high risk for multi-drug resistant organism (MDRO) transmission due to their wounds. Additionally, a licensed practical nurse did not perform hand hygiene before and between administering medications to three residents, as observed and later confirmed by both the nurse and the Director of Nursing. Furthermore, the Activity Director fed two residents consecutively without performing hand hygiene between residents. This was acknowledged by the Activity Director and confirmed by the Director of Nursing. These lapses in infection control practices were identified through direct observation, interviews, and record reviews.