Failure to Follow Infection Control and PPE Protocols
Penalty
Summary
Surveyors observed multiple failures in infection prevention and control practices among staff during direct resident care. Staff members, including an agency LPN and CNAs, did not perform hand hygiene before and after entering or exiting resident rooms, nor after direct contact with residents. The same blood pressure device was used on several residents consecutively without cleaning or disinfecting it between uses. Staff also failed to perform hand hygiene when donning and doffing gloves and PPE, and reusable medical equipment such as blood pressure cuffs and pulse oximeters were not sanitized between residents. In rooms with Enhanced Barrier Precautions (EBP) signage, staff did not follow required protocols. Staff were observed entering rooms and providing care, such as medication administration and vital sign checks, without performing hand hygiene or properly donning and doffing PPE, including gowns and gloves. In one instance, a CNA provided activities of daily living (ADL) care, including changing linens and briefs for a resident with chronic wounds and a gastrostomy tube, without wearing a gown as required by EBP protocols. Another CNA, identified as an orientee, also failed to wear a gown while handling soiled linens and entering and exiting the resident's room. Interviews with the Director of Nursing confirmed that staff are expected to perform hand hygiene and sanitize reusable equipment between residents to prevent infection. However, the facility was unable to provide a policy for cleaning reusable medical equipment when requested by surveyors. The facility's existing hand hygiene and infection control policies require routine handwashing and maintenance of necessary equipment, but these were not followed as observed during the survey.