Multiple Infection Control Failures in Resident Care and Isolation Practices
Penalty
Summary
The facility failed to implement and maintain effective infection prevention and control practices for multiple residents, resulting in several deficiencies. For residents with indwelling urinary catheters and wounds, such as those with orders for enhanced barrier precautions (EBP), the required signage indicating isolation status was not posted in or outside their rooms. In one instance, a resident with a confirmed Clostridioides difficile (C. diff) infection did not have contact precaution signage posted, and family members were observed entering the room without personal protective equipment (PPE) or education on infection risks. Staff interviews confirmed that appropriate isolation precautions were not implemented despite physician orders and facility policy requirements. During medication administration, an LPN failed to properly disinfect a glucometer between uses for different residents. The same disinfectant wipe was used to clean the glucometer after one resident's blood glucose check and then reused for another resident, contrary to manufacturer instructions and facility policy, which specify single-use and proper dwell time for disinfection. The LPN also acknowledged not following the required drying time for the disinfectant to be effective. This practice was observed and confirmed through staff interviews. In another incident, a CNA providing incontinence care to a resident with a stage four pressure ulcer inadvertently wiped feces into the wound bed before wound care was performed. The LPN performing the wound care acknowledged that feces in the wound bed was problematic and had occurred previously, requiring additional cleansing. Additionally, during tube feeding administration for a resident with a gastrostomy tube, an LPN touched the floor with gloved hands and did not change gloves or perform hand hygiene before continuing the procedure. These actions were observed and confirmed by staff, and were not in accordance with facility infection control policies.