Failure to Adhere to Infection Control Practices for Residents on Precautions
Penalty
Summary
Staff failed to consistently implement and maintain infection prevention and control practices for residents on Enhanced Barrier Precautions (EBP) or Contact Precautions. Multiple staff members, including CNAs and a laboratory technician, were observed not performing hand hygiene at required intervals, such as before entering and after exiting resident rooms, and after removing gloves. In several instances, staff exited rooms wearing gloves or failed to remove gloves and perform hand hygiene as required by facility policy and posted precaution signs. Additionally, staff did not always adhere to the use of appropriate personal protective equipment (PPE) during high-contact care activities. For example, a laboratory technician obtained a blood sample from a resident with a tracheostomy without wearing a gown, and a CNA provided activities of daily living care to a resident with a tracheostomy and gastrostomy without wearing a gown, contrary to the facility's EBP policy. Some staff members were unaware of the specific PPE requirements for residents on EBP, indicating a lack of understanding or training regarding infection control protocols. There were also lapses in the handling and use of PPE, such as a staff member using a surgical mask stored in her pocket instead of obtaining a clean mask from the designated supply area. Staff interviews confirmed a lack of knowledge about the necessity of hand hygiene and proper PPE use for residents on precautions. These actions and inactions resulted in the facility's failure to follow its own infection control policies and posted precaution signs, thereby not preventing the potential development and spread of infections among residents.