Failure to Maintain Effective Infection Control and Prevention Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in hand hygiene and use of personal protective equipment (PPE) during care of residents on Enhanced Barrier Precautions (EBP) and during medication administration. For one resident with a skin tear requiring EBP, a nurse performed wound care but did not cleanse her hands between removing contaminated gloves and donning a new pair, contrary to facility policy and CDC guidelines. The nurse acknowledged the omission and recognized that it could contribute to the spread of infection. Another resident with open skin areas on both arms, also on EBP, was observed while a CNA changed bed linens without donning a gown, despite signage and facility policy requiring gown and glove use for high-contact care activities such as changing linens. The CNA stated she believed a gown was not required if the linens were not soiled, and the DON initially confirmed this misunderstanding before reviewing the policy and signage, which clarified that a gown was indeed required for this activity. Additionally, the Infection Preventionist (IP) was observed failing to perform hand hygiene after doffing PPE and before donning new PPE during consecutive fingerstick blood glucose tests for two residents. The IP did not cleanse hands after removing gloves and gown, nor before entering the next resident's room, despite handling potentially contaminated items and equipment. The IP later acknowledged that hand hygiene should have been performed between these steps to prevent potential contamination.