Failure to Adhere to Infection Prevention and Control Protocols During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple staff not adhering to established protocols during resident care. During wound care for a resident with pressure ulcers, a registered nurse changed gloves five times without performing hand hygiene between glove changes, contrary to facility policy and training. The nurse admitted to being unaware of the requirement for hand hygiene between glove changes, and the Director of Nursing confirmed this was a breach of infection control standards. In another instance, a certified nursing assistant provided perineal care to a resident with severe cognitive impairment without donning a gown, as required by Enhanced Barrier Precautions (EBP), and failed to perform hand hygiene between glove changes. The CNA also used contaminated gloves to retrieve additional wipes from a package and did not place a barrier on the table or gather all necessary supplies before starting care. The CNA acknowledged these lapses and stated she had received training on both hand hygiene and EBP but failed to follow procedures during the care. Additionally, a licensed practical nurse performed PEG site care for a resident with severe cognitive impairment without wearing a protective gown, as required by EBP. The LPN admitted to not wearing the gown and recognized this as an infection control issue. The Director of Nursing confirmed that a gown should have been worn during this procedure. These incidents demonstrate a failure to follow the facility's infection prevention and control policies during direct resident care.