Failure to Adhere to Infection Control and Hand Hygiene Protocols
Penalty
Summary
Staff failed to follow appropriate infection prevention and control practices for three residents requiring Enhanced Barrier Precautions (EBP) or other infection control measures. For one resident with an indwelling Foley catheter, a CNA transferred the resident without donning gown or gloves, and an LPN entered the room without performing hand hygiene, then hugged and repositioned the resident without using required PPE. Both staff members acknowledged the lapses in infection control. For another resident with a nephrostomy, an LPN entered the room without hand hygiene, donned gloves but not a gown, and began a dressing change. After being prompted by a surveyor, the LPN washed hands, donned a gown, and completed the procedure, but then disposed of the dirty dressing in the hallway while still wearing contaminated PPE. The LPN admitted to not following EBP or proper hand hygiene protocols. A third resident, who was being treated for MRSA and had diabetes, received an injectable medication from a nurse who failed to perform hand hygiene before donning gloves and after removing them. The nurse admitted to missing these steps despite having received prior education on hand hygiene. The facility's policy required hand hygiene before and after glove use, between resident contacts, and prior to medication preparation, but these protocols were not followed during the observed incidents.