Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
Staff failed to adhere to infection prevention and control protocols for three residents during care activities. For one resident on enhanced barrier precautions (EBP), staff exited the resident's room without removing personal protective equipment (PPE), re-entered the room without donning new PPE, and transferred the resident using a lift without wearing required gowns. Additionally, the lift was not sanitized after use and was left in the hallway. Staff interviews confirmed knowledge of the correct procedures, but these were not followed during the observed events. During pericare for two other residents, staff did not change gloves or perform hand hygiene between dirty and clean tasks, and touched clean items in the residents' rooms with soiled gloves. In one instance, a used bed pan was stored on the floor of a resident's room. In another, clean washcloths were placed in an unsanitized sink and then used for pericare. Staff interviews confirmed that these actions were inconsistent with facility policy and proper infection control practices.