Failure to Adhere to Infection Control Protocols and PPE Use
Penalty
Summary
Staff failed to follow established infection prevention and control protocols for residents on contact precautions and enhanced barrier precautions. For one resident with a multidrug-resistant organism wound infection, staff did not consistently use required personal protective equipment (PPE) such as gowns and gloves when entering the room, despite clear signage. Multiple staff members, including a registered nurse, a certified nursing assistant, and a dietary manager, entered the resident's room without donning appropriate PPE or performing hand hygiene as directed. Staff were observed delivering medications, handling food trays, and assisting with resident care without adhering to contact precaution requirements, and in some cases, moved between rooms and common areas without performing hand hygiene after contact with the resident or their environment. In another instance, staff did not follow enhanced barrier precautions for a resident's room, failing to wear gloves and gowns during close contact and not performing hand hygiene before and after resident interaction. Staff were observed assisting the resident with positioning and then handling food and beverages for other residents without changing PPE or performing hand hygiene, increasing the risk of cross-contamination. Additional deficiencies included the presence of uncleanable surfaces, such as a chair with torn, non-cleanable material in a resident's room, and unsanitary handling of urinals, which were found hanging inside trash cans. Housekeeping staff were also observed engaging in personal grooming activities, such as clipping and filing fingernails, and blowing their nose in common areas without performing hand hygiene afterward. These actions were inconsistent with facility policy and infection control standards, as confirmed by interviews with the infection preventionist and maintenance director.