Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for two residents during direct care activities. For one resident with a history of heart failure, diabetes, kidney failure, and other chronic conditions, who had a Foley catheter and required wound care, a registered nurse provided wound care without donning an isolation gown as required by the facility's enhanced barrier precautions policy. The nurse acknowledged during an interview that she should have worn a gown and gloves prior to providing care, and that the resident required enhanced barrier precautions for both catheter and wound care. In a separate incident, a certified nursing assistant provided incontinent care to another resident with a history of cerebrovascular disease, seizures, and dementia, who was dependent on staff for all activities of daily living and was always incontinent of urine and bowel. During the care process, the CNA failed to perform hand hygiene after removing soiled gloves and before applying clean gloves. The CNA admitted to forgetting to sanitize her hands between glove changes, which she recognized as a lapse in proper infection control practice. Interviews with the Director of Nursing and the Administrator confirmed that staff are expected to use appropriate personal protective equipment and perform hand hygiene according to facility policy. Both acknowledged that failure to follow these protocols could place residents and staff at risk for infection, and that the individuals providing care are responsible for adhering to infection control procedures.