Failure to Follow Infection Prevention and Control Protocols
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices among staff members during resident care. Staff, including CNAs, LPNs, RNs, and housekeeping, were observed not performing proper hand hygiene, not using gloves and gowns as required, and contaminating clean supply fields during wound care. For example, during wound care for a resident with open wounds, staff failed to change gloves and perform hand hygiene between tasks, touched clean supplies with soiled gloves, and placed potentially contaminated items back into shared storage. Staff also failed to follow contact precaution protocols for residents with infectious conditions such as Clostridium difficile, including not wearing required personal protective equipment (PPE) and not performing hand hygiene before and after resident contact. Several residents with significant medical needs, such as those with stage IV pressure ulcers, C. difficile infections, and indwelling medical devices, were not provided care in accordance with established infection control policies. Staff did not consistently use gowns and gloves during high-contact care activities, such as transferring, dressing, and providing hygiene to residents on enhanced barrier precautions (EBP). In some cases, staff were unsure of the requirements for EBP or the location of necessary PPE, and there were instances where mechanical lifts were not sanitized between uses for different residents. The facility also failed to ensure that hand hygiene supplies, such as alcohol-based hand sanitizer (ABHS) and soap, were readily available and functional in resident rooms and bathrooms. Multiple rooms lacked ABHS dispensers or had dispensers that were empty or nonfunctional, and some rooms lacked soap. Housekeeping staff did not routinely check or refill these supplies, despite this being a stated responsibility. Facility policies required accessible hand hygiene products and outlined specific hand hygiene moments, but these were not consistently followed by staff during the survey period.