Failure to Follow Infection Control Standards During Resident Care
Penalty
Summary
Surveyors identified failures in infection prevention and control practices for three residents during observed care activities. For one resident with a colostomy and catheter, a CNA donned appropriate PPE and performed hand hygiene after changing the colostomy bag, but a nurse who assisted with the procedure failed to apply a gown before providing care and did not perform hand hygiene prior to donning gloves. The facility's policy required enhanced barrier precautions, including gown and gloves, for high-contact care activities involving indwelling medical devices, which was not followed in this instance. Additional observations revealed that a CNA did not perform hand hygiene after removing soiled gloves and before applying a clean brief to another resident during perineal care. In a separate incident, a CNA assisted a resident with toileting, removed soiled gloves, and then applied clean gloves without performing hand hygiene, and also did not offer hand hygiene to the resident. These actions were inconsistent with the facility's infection control policies, which require hand hygiene after glove removal and between procedures.