Failure to Adhere to Infection Prevention and Control Protocols
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed deficiencies in staff adherence to established protocols. In one instance, a resident with a gastrostomy tube, who was identified as requiring Enhanced Barrier Precautions (EBP) due to increased risk of multidrug-resistant organism (MDRO) acquisition, did not receive care in accordance with EBP guidelines. The assigned CNA provided a bed bath, oral care, brief change, and linen change to the resident while wearing only gloves, omitting the required gown. The CNA admitted to not using the correct PPE for all EBP-designated residents on her hall, citing lack of PPE availability at the point of care and uncertainty about where to obtain supplies, despite facility policy and signage indicating the need for both gown and gloves during direct care activities. During meal service on another hall, a CNA was observed repeatedly failing to follow proper hand hygiene and gloving procedures. The CNA served and prepared meals while wearing the same pair of gloves, touching various surfaces, utensils, and food items, including bread rolls, without changing gloves or performing hand hygiene between tasks. The CNA also used gloves obtained from a co-worker's pocket and handled clean utensils with unwashed hands after glove removal. The CNA confirmed these lapses in practice, acknowledging that she did not follow the required procedures for hand hygiene and glove use during meal service for multiple residents. Additionally, improper infection control practices were observed during wound care for a resident with pressure ulcers and blisters. The treatment nurse used gloved hands to move the bedside table and then proceeded to apply wound dressings without changing gloves or performing hand hygiene. The nurse also touched her gown and clothing before continuing wound care on a different site, again without changing gloves or sanitizing hands. The nurse confirmed these actions, recognizing that they did not align with proper infection control protocols as outlined in facility policy.