Failure to Implement Infection Prevention and Control Practices
Penalty
Summary
Facility staff failed to implement proper infection prevention and control practices in several observed instances. During a peripherally inserted central catheter (PICC) line dressing change for a resident with acute osteomyelitis, ESBL infection, and diabetes, the MDS Coordinator placed soiled gloves in the sterile field and did not wear a gown as required by Enhanced Barrier Precautions (EBP). The resident's care plan and physician orders specified the use of EBP due to the presence of a central line and wound, but these precautions were not followed during the procedure. Hand hygiene protocols were not consistently observed during medication administration and tube feeding. A medication aide failed to perform hand hygiene between glove changes and when switching between different routes of medication administration for a resident. Similarly, an LPN did not perform hand hygiene between glove changes or before handling equipment and did not wear a gown while administering tube feeding to a resident on EBP, despite signage indicating the requirement for a gown. Additionally, nebulizer machines and tubing were repeatedly observed placed directly on the floor in the rooms of two residents. Both staff and residents confirmed that this was a common practice, and staff interviews acknowledged that this created an infection control risk. These observations demonstrate multiple lapses in infection prevention practices, including improper use of personal protective equipment, failure to maintain sterile fields, and inadequate hand hygiene.