Failure to Adhere to Infection Control Protocols During Resident Care and Meal Service
Penalty
Summary
Surveyors identified that the facility failed to maintain an effective infection prevention and control program, as evidenced by multiple staff not adhering to established protocols. One incident involved a Licensed Practical Nurse who did not wear a gown while providing wound care to a resident on enhanced barrier precautions, despite clear policy and physician orders requiring gown and glove use for high-contact care. The resident in question had severe cognitive impairment, a pressure ulcer, and was under specific orders for enhanced barrier precautions. The nurse acknowledged awareness of the requirement but did not comply during the observed treatment. Additional deficiencies were observed during meal service, where home health aides failed to perform proper hand hygiene between assisting residents. One aide did not sanitize hands after handling various objects and before feeding a resident, while another did not perform hand hygiene after feeding one resident and before assisting another. Staff interviews confirmed knowledge of hand hygiene protocols, and management reported ongoing education and audits, but the observed lapses demonstrated non-compliance with infection control policies.