Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program for two residents observed for infection control. For one resident with a history of septicemia, paraplegia, pressure ulcers, and a Foley catheter, a registered nurse did not use the required personal protective equipment (PPE) during wound care. Although Enhanced Barrier Precautions (EBP) signage was posted, there was no PPE available outside or inside the room. The nurse performed hand hygiene and wore gloves but did not don a gown as required for residents with wounds and indwelling devices. The nurse acknowledged the omission and attributed it to the absence of PPE supplies at the point of care. In a separate incident, an agency certified nursing assistant (CNA) failed to perform proper hand hygiene while providing incontinence care to another resident with severe cognitive impairment and total dependence on staff for toileting. The CNA changed gloves multiple times during the care process without performing hand hygiene between glove changes, contrary to facility policy and training. The CNA acknowledged the lapse and recognized the importance of proper hand hygiene in preventing infection. Facility policies reviewed indicated that Enhanced Barrier Precautions require the use of gowns and gloves for residents with wounds or indwelling medical devices, and that PPE should be readily available outside the resident's room. The hand hygiene policy requires staff to perform hand hygiene before and after resident contact, after glove removal, and after contact with soiled items. Both incidents were confirmed through observation, staff interviews, and record review.