Failure to Implement Infection Prevention and Control Measures
Penalty
Summary
The facility failed to implement its infection prevention and control measures as evidenced by multiple observed deficiencies. One resident with a suprapubic catheter was found with their urinary drainage bag resting on the ground near the bed, contrary to facility protocol and staff acknowledgment that the bag should be hanging. The resident denied moving the bedside table, and the nurse confirmed the bag should not be on the floor. This lapse was documented through direct observation and staff interviews. Additionally, a certified nurse aide exited the room of a COVID-positive resident wearing only a regular mask instead of the required N95 respirator, despite facility policy and posted signage specifying the need for N95 masks and full PPE for transmission-based precautions. Furthermore, a registered nurse performed wound care on a resident with a stage IV sacral ulcer and ongoing IV antibiotic therapy without changing gloves or performing hand hygiene after cleaning feces and before applying new dressings. The nurse later acknowledged the lapse, and both the infection preventionist and unit manager confirmed that proper glove changes and hand hygiene are required between tasks to prevent infection. Facility policies reviewed also supported these requirements.