Failure to Implement Infection Control Precautions and Proper Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by multiple lapses in following established protocols. A resident with a non-pressure chronic ulcer of the left lower leg, who was admitted with a diagnosis that included long-term use of anticoagulants, developed an open wound. Despite facility policy requiring enhanced barrier precautions (EBP) for residents with wounds, staff did not implement these precautions for the resident. During wound care, a registered nurse sanitized hands and donned gloves but did not wear a gown as required, and there was no EBP signage outside the resident's room. The Director of Nursing confirmed that EBP should have been in place for this resident and acknowledged the absence of appropriate signage and PPE use during wound care. Additionally, the facility did not ensure proper hand hygiene practices among staff. An activity aide was observed washing hands but then turned off the faucet with bare hands and dried hands on a t-shirt, contrary to facility policy, which requires using a disposable paper towel for both drying hands and turning off the faucet. The Director of Nursing confirmed that the observed hand hygiene practice did not comply with facility policy and acknowledged the need for staff education in this area.