Failure to Follow Infection Control Protocols and PPE Use
Penalty
Summary
Facility staff failed to adhere to infection prevention and control protocols for multiple residents requiring Enhanced Barrier Precautions (EBP), Transmission Based Precautions (TBP), and standard hand hygiene practices. For two residents with feeding tubes and immune deficiencies, staff did not consistently use required personal protective equipment (PPE) such as gowns, gloves, and masks during personal care. Staff were observed not changing gloves or performing hand hygiene between care tasks, and in some cases, did not wear masks or sanitize hands after removing PPE and before leaving the resident’s room. For a resident on contact enteric precautions due to a C. difficile infection, staff from various departments, including housekeeping and therapy, entered the room without donning gowns and gloves as required. Staff also failed to wash hands with soap and water upon exiting the room, instead using only hand sanitizer, contrary to posted instructions. Staff were observed moving between rooms and handling items for other residents without performing appropriate hand hygiene after contact with the resident on TBP. During wound care for another resident, a nurse supervisor did not change gloves or perform hand hygiene between removing soiled dressings and applying clean ones, and touched multiple surfaces and other residents’ rooms before sanitizing hands. Additionally, a resident was observed using a wheelchair with cracked and peeling armrests, which staff acknowledged could not be properly cleaned, increasing the risk of infection transmission.