Failure to Follow Infection Control Protocols for Equipment, PPE, and Resident Care
Penalty
Summary
Staff on the Cascade unit failed to follow infection prevention and control protocols regarding equipment sanitation, garbage handling, and use of personal protective equipment (PPE). Multiple staff members were observed not disinfecting mechanical lifts after use between residents, despite facility policy requiring the use of disinfectant wipes or sprays on non-critical items between uses. Staff interviews confirmed knowledge of the requirement but revealed lapses in practice, with staff either forgetting or assuming another staff member would perform the disinfection. Additionally, a staff member was observed leaving a room with enhanced barrier precautions (EBP) signage and not cleaning the lift, even though cleaning supplies were readily available. In another instance, a staff member was observed handling garbage in a resident room with EBP signage without wearing gloves, using bare hands to push down the garbage before removing the bag. The staff member acknowledged not wearing gloves and cited being told not to wear gloves in the hallway, but no further explanation was provided. This action was inconsistent with infection control standards, especially in rooms requiring enhanced precautions. Deficiencies were also noted in the use of PPE during resident care. For a resident with chronic wounds and EBP in place, staff provided high-contact care, including pericare, dressing, and transferring, while only wearing gloves and not gowns as required by the posted EBP instructions. Both staff involved acknowledged after reading the sign that gowns should have been worn but stated they forgot. Additionally, during pericare for another resident, staff failed to change gloves and perform hand hygiene after cleaning the perineal area and before applying a clean brief, and touched clean items and the environment with contaminated gloves. Staff interviews confirmed awareness of the correct procedures but admitted to not following them during the observed care.