Failure to Follow Infection Control Precautions and Hand Hygiene Protocols
Penalty
Summary
Facility staff failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in following established precautions. In one instance, a respiratory therapy nurse entered the room of a resident who was under contact precautions for metapneumovirus without wearing any personal protective equipment (PPE), despite clear signage on the door and a banner in the electronic health record indicating isolation status. The nurse stated she was unaware of the required precautions and mask use. Additionally, there was no physician order for contact precautions in the resident's record, although the Center Nurse Executive confirmed the resident was on isolation for a communicable virus. In another case, a resident with a right arm wound and an order for enhanced barrier precautions was observed during a dressing change performed by an LPN. The LPN did not wear a gown as required by facility policy and failed to perform hand hygiene at appropriate points during the procedure. Specifically, the LPN did not change gloves or perform hand hygiene between removing the soiled dressing and cleaning the wound, nor before applying a new dressing. The Center Nurse Executive confirmed that these actions were inconsistent with facility policy and staff training.