Infection Control Deficiencies: Hand Hygiene, PPE, and Linen Management
Penalty
Summary
Multiple deficiencies in infection prevention and control were observed throughout the facility, including failures in hand hygiene, use of personal protective equipment (PPE), and linen management. During incontinent care for a resident, staff members failed to remove contaminated gloves and perform hand hygiene between tasks, instead touching clean briefs, drawers, and applying skin barrier with soiled gloves. Staff interviews confirmed a lack of adherence to proper glove removal and hand hygiene protocols during perineal care. Staff did not consistently follow transmission-based precautions for residents who tested positive for COVID-19. Several staff members entered rooms of COVID-19 positive residents without the required N95 respirators, gowns, gloves, or eye protection, despite clear signage indicating these requirements. In some cases, staff wore only surgical masks or failed to change PPE between resident rooms, and one staff member entered a room without any N95 masks available. Staff interviews revealed gaps in understanding and compliance with PPE protocols, including the need for N95 respirators and eye protection. Enhanced Barrier Precautions (EBP) were not properly implemented for residents with wounds or indwelling devices. Staff provided direct care, such as wound care and IV antibiotic administration, without donning gowns as required by EBP protocols. Additionally, clean linens were transported into the facility uncovered and handled with bare hands, contrary to facility policy. Interviews with staff and leadership indicated incomplete education on EBP and infection control procedures, contributing to the observed non-compliance.