Failure to Adhere to Infection Control Protocols and PPE Use
Penalty
Summary
Facility staff failed to adhere to infection prevention and control protocols, specifically regarding the use of Enhanced Barrier Precautions (EBP) and personal protective equipment (PPE) during resident care. Staff did not consistently wear gowns and gloves when providing wound care and Foley catheter care to residents who were on EBP, despite signage and the presence of PPE carts. Interviews with staff, including CNAs and LVNs, revealed a lack of compliance and understanding of when PPE was required, even though the Director of Nursing and Director of Staff Development confirmed that PPE should be used during these activities. Residents involved had significant medical histories, including sepsis, MRSA, indwelling catheters, and multiple wounds, increasing their risk for infection. Hand hygiene practices were also not followed as required. During wound treatment observations, an LVN failed to perform hand hygiene between glove changes and after touching various surfaces and supplies, despite acknowledging the need to do so. The facility's policy required hand hygiene to prevent the spread of infection, but this was not consistently implemented during care activities, including wound dressing changes and feeding assistance. Additionally, infection control lapses were observed in the storage and labeling of respiratory and suction equipment. A resident's nebulizer mouthpiece and suction tubing were found unlabeled and improperly stored, in contact with potentially contaminated surfaces and personal items. Staff confirmed these practices were not in line with facility policy, which required proper cleaning, labeling, and storage of such equipment. These failures in infection control practices had the potential to result in cross-contamination and the spread of infection among the facility's residents.