Failure to Follow Infection Prevention and Control Practices
Penalty
Summary
Facility staff failed to follow standard infection prevention and control practices for four sampled residents, as observed through direct care activities and confirmed by staff interviews and record reviews. For two residents requiring pulse oximetry monitoring, the respiratory therapist did not sanitize the pulse oximeter and sensor before and after each use, despite handling the device between residents and storing it in a shirt pocket. Both the infection prevention director and the director of nursing confirmed that the facility's policy required sanitizing the device before and after use, and that failure to do so could transmit infectious organisms between residents. In another instance, a registered nurse did not don a gown while administering medications and checking the gastrostomy tube of a resident with an indwelling device, despite the facility's policy requiring enhanced standard precautions, including gown use, for such procedures. The nurse acknowledged the omission and stated that PPE is necessary to prevent contamination and infection from bodily fluids. The infection prevention director and director of nursing both confirmed that a gown should have been worn to prevent cross-contamination. Additionally, during tracheostomy care for another resident, a registered nurse failed to change gloves and perform hand hygiene between tasks, placed used dressings and an inner cannula on the resident's bedside table alongside clean supplies, and did not sanitize the table after disposing of the used items. The nurse admitted to not following the facility's policy for glove changes and proper disposal of used supplies. The infection prevention director and director of nursing confirmed that these actions were inconsistent with facility policies and could result in contamination of the environment and equipment.