Failure to Maintain Infection Control Practices During Resident Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in infection control practices among staff caring for residents on Enhanced Barrier Precautions (EBP) and during routine care. In several instances, staff members did not adhere to required protocols for the use of personal protective equipment (PPE), glove changes, and hand hygiene. For example, a CNA was observed leaving a resident's room while still wearing the same gown and gloves used during direct care, then returning and continuing care without changing gloves. The same CNA also picked up linens from the floor, placed them in a bag, and resumed care without changing gloves. Another CNA picked up a plastic bag from the floor and placed it on a resident's bed during care. Additional observations included staff not wearing gloves or gowns throughout the entirety of care for a resident on EBP, and failing to change gloves between dirty and clean surfaces during incontinent care. Residents involved in these deficiencies had significant medical histories and care needs. One resident was dependent on staff for most activities of daily living, had moderate cognitive impairment, was always incontinent, and was on EBP due to a multidrug-resistant organism (MDRO) infection. This resident also had chronic kidney disease, diabetes, and a history of urinary tract infection with ESBL resistance. Another resident required total assistance with toileting, transfers, bathing, and bed mobility, and was observed receiving care where gloves were not changed between dirty and clean tasks, and hand hygiene was not performed between glove changes. A third resident, with chronic obstructive pulmonary disease and diabetes, was observed during a blood glucose check where the nurse failed to remove gloves or perform hand hygiene before handling the insulin pen and nurse’s cart, despite having just obtained a blood sample. Interviews with staff, including CNAs, LVNs, the DON, and the Administrator, confirmed knowledge of proper infection control procedures, such as changing gloves between dirty and clean tasks, performing hand hygiene, and not wearing PPE outside of resident rooms. However, the observed failures demonstrated a lack of consistent adherence to these protocols. Facility policies reviewed also outlined the correct procedures for perineal care, hand hygiene, and blood glucose monitoring, emphasizing the importance of glove changes and hand hygiene to prevent cross-contamination and infection.