Infection Control Failures in Waste Handling, Barrier Precautions, and TB Screening
Penalty
Summary
Staff failed to follow infection control procedures in several areas of the facility. Certified nursing assistants (CNAs) were observed transporting untied plastic trash bags to utility rooms and placing them on top of overflowing, uncovered trash bins. The utility rooms near two nurses' stations had foul odors, and the trash bins did not have lids. Both the Housekeeping Supervisor and Director of Staff Development confirmed that staff were expected to tie trash bags and cover bins, but these procedures were not followed. A licensed nurse provided wound care to a resident with a sacral pressure ulcer who was under enhanced barrier precautions (EBP) due to infection risk. Despite a posted EBP sign and a physician's order requiring gown and glove use during high-contact care, the nurse performed the wound treatment without wearing a gown. The nurse acknowledged forgetting to wear the gown and confirmed that gown use was required for infection prevention during such procedures. Additionally, newly admitted residents were not screened for tuberculosis (TB) upon admission as required by facility policy. Two residents were identified as not having received TB testing at the time of admission, with one resident only receiving the test several days later. The Infection Preventionist and Director of Nursing both stated that TB screening should occur upon admission to prevent the spread of infectious disease among vulnerable residents.