Failure to Implement Infection Control Practices for Staff Illness, Hand Hygiene, and Nebulizer Cleaning
Penalty
Summary
The facility failed to establish and implement clear criteria for employee illness and appropriate return to work, as evidenced by the review of illness forms and timecards for three sampled staff members. Employees returned to work following symptoms such as diarrhea, nausea, fever, and respiratory issues without documentation of symptom resolution or assessment of contagion risk. The infection preventionist and director of nursing both acknowledged the absence of a consistent process to determine when staff were safe to return, and logs lacked adequate surveillance and monitoring of employee illnesses. Staff did not perform appropriate hand hygiene while assisting residents with meals in the dining room. One nurse aide was observed assisting multiple residents with eating, using the same gloved hand without changing gloves or performing hand hygiene between residents or tasks. The aide also wiped a resident’s mouth with the resident’s clothing and continued to assist others without changing gloves. The infection preventionist confirmed that staff were expected to change gloves and use hand sanitizer between residents, but the last audit of dining room hand hygiene had been about a year prior. The facility also failed to follow manufacturer’s instructions for cleaning nebulizer administration sets. A resident receiving nebulized medications for COPD had equipment that was not rinsed or air-dried after each use, as required. Staff and the director of nursing were unaware of the need for cleaning after each use, and the facility’s policy did not include these instructions. The infection preventionist was aware of the correct procedure but was not monitoring compliance, and there was no evidence of staff training on this requirement.