Inconsistent Infection Control Practices and PPE Use
Penalty
Summary
Surveyors identified multiple failures in the facility's infection prevention and control program, specifically related to the handling of bedpans, use of personal protective equipment (PPE), and management of soiled materials. In several instances, bedpans used by residents who lacked in-room bathrooms or sinks were placed directly on the floor under their beds without being contained in plastic bags or other containers. This practice was confirmed by both staff and residents, and it was noted as a common occurrence in rooms without bathrooms. The Director of Nursing was unaware of this practice and stated that bedpans should be bagged and stored on wardrobes, not on the floor. Staff inconsistently implemented Enhanced Barrier Precautions (EBP) and contact precautions for residents requiring them. For example, staff members providing care to a resident with an indwelling catheter and on EBP failed to don isolation gowns as required, despite signage and facility policy. One CNA reported being told by a nurse that only gloves were necessary, leading to confusion and non-compliance. Additionally, soiled incontinence briefs and linens were discarded directly onto the floor rather than into designated containers, contrary to facility policy. Environmental hygiene issues were also observed, particularly in rooms with carpeted floors and bedside commodes. Staff and environmental services confirmed that commodes often leaked or were missed, resulting in urine and feces on the carpet and privacy curtains. Observations confirmed the presence of bodily waste on both the carpet and curtains in a resident's room. In another case, a staff member entered the room of a resident on contact precautions without wearing any PPE, despite clear signage and physician orders requiring gown and glove use. These findings demonstrate a pattern of inconsistent infection control practices affecting multiple residents.