Failure to Adhere to Infection Control Practices and PPE Use
Penalty
Summary
The facility failed to maintain proper infection control practices on two units, as evidenced by direct observations and staff interviews. On one unit, a resident with a diagnosis of Enterocolitis due to Clostridium difficile (C-diff) was under contact precautions, as indicated by physician orders and signage outside the resident's room. Despite these precautions, a Unit Manager provided incontinence care to the resident while wearing only gloves and not a gown, as required by the facility's policy for contact precautions. The Unit Manager acknowledged during an interview that a gown should have been worn to prevent the spread of infection. On another unit, a hospice staff member was observed exiting a resident's room while wearing contaminated gloves and carrying soiled materials. The staff member disposed of the soiled items in the utility room but improperly removed her gloves, placing them in her shirt pocket instead of discarding them in the trash. The gloves subsequently fell to the floor, were picked up, and returned to her pocket. The staff member admitted she did not perform hand hygiene after glove removal, contrary to facility policy. Interviews with facility leadership confirmed that staff are expected to follow established infection control protocols, including the use of appropriate PPE and hand hygiene. The Director of Nursing also stated that outside providers, such as hospice staff, should be educated on facility infection control policies prior to providing care, but this had not occurred in this instance.