Failure to Implement Infection Control Practices and Maintain Sanitary Conditions
Penalty
Summary
The facility failed to implement proper infection prevention and control practices for three of ten sampled residents. In one instance, a Licensed Vocational Nurse (LVN) did not wear a gown while conducting a gastrostomy tube (G-tube) assessment on a resident who was under Enhanced Barrier Precautions (EBP) due to the presence of a G-tube. The resident had severe cognitive impairment and required family involvement in care planning. The LVN acknowledged awareness of the EBP sign and the requirement to wear a gown during high-contact care but did not follow the procedure, as confirmed by the Director of Nursing (DON). In another case, a Certified Nursing Assistant (CNA) did not wear a gown while providing incontinence care to a resident on EBP for a wound. The resident had intact cognition and participated in care planning. The CNA admitted to not checking the EBP sign and not wearing the required gown during high-contact care, which was also confirmed as a lapse by the DON and another LVN. Facility policy required the use of PPE, including gowns, during such care activities for residents on EBP. Additional deficiencies were observed in the facility's laundry and respiratory therapy practices. Personal water bottles and drinking containers were found in the clean laundry room, contrary to facility policy prohibiting personal items in laundry areas to prevent cross contamination. Staff interviews confirmed a lack of adherence to this policy. Furthermore, a resident's BiPAP/CPAP tubing was observed touching the floor instead of being stored in a plastic bag as required by facility policy, with staff acknowledging the tubing should have been kept clean and off the floor to prevent contamination.