Failure to Follow Infection Control Protocols for Residents on Contact Precautions
Penalty
Summary
Staff failed to follow infection prevention and control protocols for two residents with significant medical needs. One resident, who had a history of malignant neoplasm of the glottis, COPD, chronic respiratory failure, and a tracheostomy, was on contact precautions due to a Clostridioides difficile (C. diff) infection. Despite clear signage indicating contact precautions, multiple staff members, including two CNAs and an RN, entered the resident's room and provided direct care without donning the required personal protective equipment (PPE) such as gowns and gloves. Both the CNAs and the RN acknowledged after the fact that they were aware of the contact precautions and should have worn PPE while in the room. Another resident, with diagnoses including myotonic muscular dystrophy, chronic respiratory failure, encephalopathy, and heart failure, required assistance with toileting and personal hygiene. During an observed episode of incontinence care, a CNA and an LPN donned PPE before entering the room and transferred the resident using a full body lift. However, the CNA did not perform hand hygiene between glove changes, did not cleanse the resident's entire perineal area after a soiled brief was removed, and failed to change gloves before applying barrier cream. The CNA also continued to perform tasks such as changing the resident's gown and cleaning equipment without completing hand hygiene between glove changes, contrary to facility policy. Interviews with staff, including the CNA, LPN, DON, and the Nursing Home Administrator, confirmed that the observed actions did not align with the facility's policies on hand hygiene, perineal care, and transmission-based precautions. The facility's policies require staff to perform hand hygiene before and after glove use, cleanse the entire perineal area during care, and don appropriate PPE for residents on contact precautions. These lapses in infection control practices were directly observed and acknowledged by staff during interviews.