Failure to Adhere to Infection Control Practices During Resident Care
Penalty
Summary
Staff failed to adhere to infection prevention and control standards during wound care, suctioning, and tube feeding for multiple residents. In one instance, a staff member performed a dressing change on a resident's right heel without changing gloves or performing hand hygiene between removing the soiled dressing and applying the clean one. The wound was not cleansed prior to dressing, and the staff member did not wear a gown as required by Enhanced Barrier Precautions (EBP). The staff member also left the resident's room without removing gloves, contrary to facility policy. Another resident on EBP had tube feeding and suctioning performed by staff who only wore gloves, omitting the required gown. Staff cleaned up leaked tube feeding and handled suction equipment without donning gowns, and did not follow proper procedures for disposing of suction contents. Observations also revealed that staff did not perform hand hygiene before or after care, or after removing personal protective equipment, as required by facility policy. A third resident receiving wound care had staff who donned PPE but failed to change gloves or perform hand hygiene after touching potentially contaminated surfaces, such as the door and bed linens. Supplies were handled and placed on various surfaces without proper glove changes or hand hygiene. After completing care, the staff member disposed of trash without gloves and did not perform hand hygiene before handling medication cards. Interviews confirmed that staff were aware of infection control policies but did not consistently follow them during care.