Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for three residents, as observed during care activities. In one instance, a certified nursing assistant (CNA) provided incontinent care to a resident with a history of Alzheimer's disease, dementia, and a recent urinary tract infection. The CNA did not remove gloves or perform hand hygiene after cleaning the resident's buttocks and before applying a clean brief, despite being trained and aware of the correct procedure. The facility's policy required glove removal and hand hygiene between contaminated and clean tasks, but this was not followed during the observed care. In another case, a CNA caring for a resident with cerebral palsy, diabetes, and an indwelling urinary catheter failed to change gloves after cleaning the resident's buttocks and before handling a new, clean brief. The CNA admitted to the mistake during an interview, acknowledging that gloves should have been changed and hands sanitized before touching clean items. The facility's policy on perineal care also specified glove removal and hand hygiene before handling clean briefs, but this protocol was not adhered to during the observed care. Additionally, a licensed vocational nurse (LVN) administered medications via gastrostomy tube to a resident with multiple sclerosis, dementia, and a feeding tube, who was under enhanced barrier precautions. The LVN wore gloves but did not don a gown as required by the posted enhanced barrier precaution guidelines, which specifically mandated both gloves and gown for high-contact care activities involving feeding tubes. The LVN acknowledged forgetting to wear the gown, and the assistant director of nursing confirmed that the facility followed these guidelines, even though there was no formal written policy.