Failure to Ensure Staff Competency in Infection Control Procedures
Penalty
Summary
The facility failed to ensure that nurses and nurse aides possessed and demonstrated the necessary competencies in infection control procedures required to meet residents' needs. Specifically, a registered nurse did not wear a gown and failed to change gloves after touching items in the resident's environment while providing care to a resident with a peripherally inserted central catheter (PICC) line. Additionally, two nursing assistants repositioned a resident on Enhanced Barrier Precautions, who had a gastrostomy tube and a wound positive for MRSA, without donning the required personal protective equipment (PPE) such as gowns and gloves. These lapses were observed during direct care activities and involved all three staff members reviewed for infection control practices. Review of employee records revealed that there was no documented evidence of competency checks or infection control in-service education for the involved staff members. Sign-in sheets for mandatory infection control education did not include signatures from the nurse and nursing assistants involved in the observed deficiencies. Interviews with the Infection Preventionist and the Director of Nursing confirmed that there was no clear system in place to track completion of required training or to verify staff competencies, particularly regarding PICC line care and adherence to infection control protocols during resident care.