Failure to Follow Infection Control Protocols and Transmission-Based Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple lapses in following transmission-based precautions and proper hand hygiene protocols. For one resident with pressure ulcers and an ESBL urinary tract infection, an LPN performed dressing changes and incontinence care without performing hand hygiene between glove changes, despite facility policy requiring hand hygiene when moving between contaminated and clean body sites. The LPN acknowledged not performing hand hygiene during these procedures. Additionally, a nursing assistant was observed feeding the same resident in their room without wearing required personal protective equipment (PPE), such as a gown and gloves, and was unaware of the resident's updated contact isolation status. Another resident, under contact isolation and enteric precautions for C. difficile, was also not provided appropriate infection control measures. A nursing assistant entered the resident's room to deliver and set up a meal tray without donning a gown or gloves, touched the resident and their environment, and upon leaving, used hand sanitizer instead of washing hands with soap and water as required for C. difficile precautions. The nursing assistant believed the precautions only applied to direct care, not tray delivery. The Director of Nursing confirmed that contact enteric precautions applied to all staff entering the room.