Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple staff members not following proper hand hygiene and glove-changing protocols during resident care. Specifically, while providing colostomy care to a resident with Alzheimer's disease, ileostomy status, and other comorbidities, an LVN touched the privacy curtain with gloved hands and did not change gloves or sanitize hands before starting the procedure. The LVN acknowledged not realizing the risk of cross-contamination, despite having received infection control training within the year. In another instance, a resident with chronic kidney disease, aphasia, diabetes, hemiplegia, and pressure ulcers received wound care from an LVN who also touched the privacy curtain with gloved hands and failed to change gloves or sanitize hands before beginning wound care. The LVN admitted she should have changed gloves and washed her hands, recognizing the curtain as a contaminated surface. This resident also received incontinent care from a CNA who did not change gloves or sanitize hands during the entire care process, including after cleaning the genital area and before handling a clean brief. The CNA stated he did not think glove changes were necessary, despite having received infection control training. Interviews with the Director of Nursing confirmed that staff are expected to change gloves after touching environmental surfaces like privacy curtains and during care to prevent cross-contamination. Facility policy on hand hygiene requires handwashing or sanitizing before and after direct resident contact, after contact with objects in the resident's vicinity, and when moving from contaminated to clean body sites. These observed failures to follow established infection control protocols were documented during surveyor observations and staff interviews.