Failure to Follow Infection Control Standards During Resident Care
Penalty
Summary
Staff failed to follow established infection prevention and control standards during care for three residents. For one resident with an indwelling urinary catheter, a CNA wore a gown and gloves but left the resident's room without removing them, retrieved supplies, and then returned to continue care. The CNA also drained the urinary catheter bag in a manner that allowed the bag and tip to touch the sides of the graduate, and performed multiple care tasks without changing gloves or performing hand hygiene as required by facility policy. For another resident with a left heel ulcer, a nurse applied Silvadene ointment to the wound using a gloved finger and did not change gloves before continuing with the dressing application. In a separate incident, two nurses performed a dressing change for a resident with a pressure injury and placed clean supplies, including wound cleanser and hand sanitizer, directly on the floor before returning them to the supply basin, failing to use a clean barrier as required. An administrative nurse confirmed that staff are expected to use barriers for clean supplies and adhere to infection control policies.