Failure to Adhere to Infection Control Standards and PPE Use
Penalty
Summary
The facility failed to adhere to infection prevention and control standards for four residents, resulting in multiple deficiencies related to the use of personal protective equipment (PPE), cleaning and disinfection of surfaces and equipment, and implementation of contact and enhanced barrier precautions. For one resident with a diagnosis of Clostridium Difficile (C-Diff), staff entered the room and handled items such as the breakfast tray and call bell without donning gloves or gowns, despite clear signage and physician orders for contact precautions. The Director of Nursing confirmed that staff should have worn appropriate PPE in these situations due to the highly contagious nature of C-Diff. In another instance, a resident's overbed table was not properly cleaned and disinfected after a used urinal was removed and before a meal tray was placed on it. The staff member used only a dry paper towel rather than a disinfectant wipe, and both the CNA and DON acknowledged that proper disinfection was not performed, which was inconsistent with facility policy and infection control standards. Additionally, shared medical equipment, specifically a portable pulse oximeter, was used on a resident with C-Diff and then on another resident after being wiped with a product not effective against C-Diff spores. The unit manager confirmed that dedicated equipment should have been used and that the cleaning product available was not appropriate for C-Diff. For a resident on Enhanced Barrier Precautions due to pressure ulcers and other conditions, staff failed to wear gowns while providing high-contact care such as feeding, repositioning, and handling bed linens, despite signage and care plan interventions requiring both gowns and gloves. Multiple staff members and the unit manager acknowledged that gowns should have been worn during these activities. These failures were observed directly by surveyors and confirmed in interviews with staff and management, demonstrating lapses in adherence to established infection control policies.