Infection Control Lapses in PPE Use, Hand Hygiene, and Precaution Signage
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices for three residents. For one resident with a diagnosis of C. difficile and on contact isolation, a CNA adjusted the resident's oxygen tubing without donning gloves, despite gloves being available and facility policy requiring glove use for contact precautions. Another resident, with multiple diagnoses including hemiplegia and dysphagia, was served a meal by a CNA who coughed into her hand and shirt collar, then delivered and set up the meal tray without performing hand hygiene until after the task, contrary to the facility's hand hygiene policy. Additionally, a third resident with an indwelling urinary catheter did not have the required enhanced barrier precaution signage posted outside the room, as confirmed by an LPN. Facility policy mandates signage for residents with indwelling medical devices to indicate the type of precautions and required PPE. These lapses were identified through observation, medical record review, staff interviews, and policy review, and affected three of five residents reviewed for infection control practices.