Failure to Implement Infection Control Practices During Resident Care
Penalty
Summary
The facility failed to implement proper infection prevention and control practices as observed during care provided to multiple residents. In one instance, a respiratory therapist entered a resident's room, donned personal protective equipment (PPE) without performing hand hygiene beforehand, and then proceeded to provide care involving cleaning and suctioning. The therapist acknowledged afterward that hand hygiene should have been performed prior to donning PPE. In another case, a licensed nurse performed peri care and then transitioned to wound care for a resident without changing gloves or performing hand hygiene between the two tasks. The nurse later confirmed that gloves should have been changed and hand hygiene performed when moving between different body sites and after peri care. Additionally, a respiratory therapist was observed providing endotracheal suctioning to a resident under Enhanced Barrier Precautions without wearing a gown, despite signage indicating that both gloves and a gown were required for such high-contact activities. The therapist admitted that a gown should have been worn during the procedure. These lapses in infection control practices were identified through direct observation and staff interviews, and were not in accordance with CDC guidance for hand hygiene and use of PPE.