Failure to Maintain Infection Control Practices During Resident Care and Meal Service
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple staff not adhering to required infection control practices during resident care and meal service. Observations revealed that a CNA did not perform hand hygiene between each resident when passing lunch trays to several residents. The CNA admitted to forgetting to use hand sanitizer between residents, despite having received training on hand hygiene and infection control. During peri-care for a resident, another CNA did not change gloves or perform hand hygiene when moving from the front to the back, which is a breach of standard infection control procedures. Additionally, an RN failed to wear a gown while administering medications via an enteral feeding tube to a resident on Enhanced Barrier Precautions, stating she forgot due to feeling nervous, even though she had been trained on the protocol. Another RN did not perform hand hygiene with each glove change while providing Foley catheter and wound care to a resident with a urinary tract infection and pressure ulcer. Interviews with the DON and Administrator confirmed their expectations for staff to follow proper hand hygiene, glove changes, and Enhanced Barrier Precautions as outlined in facility policy. The residents involved had significant medical conditions, including Alzheimer's disease, Down's syndrome, gastrostomy status, neuromuscular dysfunction, and pressure ulcers, making adherence to infection control protocols critical during their care.