Failure to Follow Infection Control Practices During Resident Care and Medication Administration
Penalty
Summary
Facility staff failed to adhere to established infection prevention and control practices during resident care activities, as observed and documented by surveyors. In one instance, a Certified Nursing Assistant (CNA) did not perform hand hygiene after leaving one resident's room and before entering another's, nor did the CNA disinfect the vital signs machine between uses on two different residents. The facility's policies required hand hygiene after touching a resident or their environment and disinfection of non-critical items, but these were not followed, as confirmed by the Infection Preventionist Nurse (IPN). In another case, a CNA did not perform hand hygiene or don personal protective equipment (PPE) before providing perineal care to a resident in an isolation room, despite physician orders for enhanced barrier precautions due to the resident's abscess and immunodeficiency. The CNA only donned PPE after being instructed by the IPN and failed to perform hand hygiene after removing PPE and before moving the resident to a common area. Both the IPN and Director of Nursing (DON) confirmed that facility policies regarding enhanced barrier precautions and hand hygiene were not followed during these care activities. Additionally, a Licensed Vocational Nurse (LVN) did not perform hand hygiene or don gloves after preparing medications and before administering them to a resident in an isolation room, despite orders for enhanced barrier precautions due to the resident's medical conditions, including sepsis and immunodeficiency. The LVN acknowledged the lapse, and both the IPN and DON confirmed that the facility's policies on medication administration, hand hygiene, and enhanced barrier precautions were not followed. These failures were observed to have the potential to result in cross-contamination among vulnerable residents.