Infection Control Deficiencies in PPE Use, Hand Hygiene, and Catheter Care
Penalty
Summary
Staff failed to maintain proper infection control practices in the COVID-positive unit, specifically regarding the donning and doffing of N95 masks. Multiple staff members, including a custodian and certified nursing assistants, were observed not changing their N95 masks after exiting rooms of residents on aerosol precautions for COVID-19. The N95 masks were located outside the unit, and staff reported changing masks only when entering or leaving the unit, rather than after each resident room as required. Signage on the unit doors instructed staff to change masks after exiting positive resident rooms, but this was not consistently followed. Hand hygiene practices were also deficient. A staff member was observed using hand sanitizer on gloved hands instead of removing gloves and performing hand hygiene as required. This practice was acknowledged by the infection preventionist and director of nursing as inappropriate and not in line with facility expectations. Urinary catheter care was not performed according to standards for two residents on Enhanced Barrier Precautions (EBP). One staff member donned PPE inside the resident's bathroom, which was identified as a potentially contaminated area, and another staff member failed to wear a gown during catheter care. Additionally, improper hand hygiene and glove changes were observed during catheter care, including touching multiple surfaces and resident items without changing gloves or performing hand hygiene between tasks. The staff also failed to use appropriate disinfectant techniques when disconnecting and reconnecting catheter tubing.