Failure to Follow Infection Control Protocols and Sanitary Practices
Penalty
Summary
Staff failed to use appropriate Personal Protective Equipment (PPE) and follow Enhanced Barrier Precautions (EBP) for residents with indwelling urinary catheters and other infection risks. For one resident with a urinary catheter, there was no EBP signage or PPE available at the room, contrary to facility policy. Another resident with an EBP sign posted had medications administered by a nurse who did not wear the required PPE, despite acknowledging the expectation to do so. A third resident with a catheter and EBP signage had their catheter bag emptied by a CNA who did not wear a gown as required, later admitting to forgetting the precaution. Hand hygiene (HH) practices were not consistently followed during meal service. One CNA delivered meal trays to multiple resident rooms, handled used items, and moved between rooms without performing HH between resident contacts or after touching items in the rooms. Another CNA also failed to perform HH between resident contacts during meal delivery, acknowledging the expectation but stating they forgot. Sanitary practices were not maintained during meal service, as one CNA dropped a mustard packet on the floor and then delivered it to a resident without cleaning or replacing it. The CNA recognized this was not appropriate for infection prevention. These observed failures were in direct violation of the facility's infection prevention and control policies, as well as state regulations.