Failure to Implement Infection Control Practices and Contact Precautions
Penalty
Summary
The facility failed to implement proper infection prevention and control practices as required by policy and regulation. Specifically, staff did not perform hand hygiene when changing gloves during wound care and gastrostomy tube care for two residents. During wound care for a resident with open areas on both arms, a registered nurse repeatedly removed soiled gloves and donned new gloves without performing hand hygiene, despite handling dressings and cleansing wounds. Similarly, during gastrostomy tube feeding and site care for another resident, the same nurse failed to perform hand hygiene between glove changes after handling feeding equipment and before cleansing the tube insertion site. Additionally, the facility did not ensure that contact precautions were followed for a resident on contact isolation due to a urinary tract infection with multi-drug resistant organisms. Observation revealed that housekeeping staff entered and cleaned the resident's room without wearing a gown, as required by the posted isolation sign and facility policy. The staff member also left the room wearing gloves and re-entered without donning a gown, indicating a lack of adherence to contact precaution protocols. The deficiencies were confirmed through staff interviews, clinical record reviews, and direct observation. Facility policies required hand hygiene before donning and after removing gloves, as well as the use of gowns and gloves for contact precautions. However, these protocols were not followed during the observed care and cleaning activities, resulting in non-compliance with infection prevention and control standards.