Failure to Follow Infection Control Practices During Resident Care and Transfers
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices during direct observation, record review, and staff interviews. Staff were observed transferring a resident with an indwelling catheter using a mechanical lift sling taken from another resident's room without sanitizing it, and without utilizing Enhanced Barrier Precautions (EBP) as required for residents with indwelling medical devices. Staff interviews confirmed that EBP should have been used during such high-contact activities, and that each resident should have their own clean sling or a properly sanitized one if shared. In another instance, staff provided incontinence care to a resident with chronic conditions including a left above-knee amputation and moisture-associated skin disorder. During care, staff failed to consistently change gloves and sanitize hands between tasks, and handled clean supplies and equipment with contaminated gloves. Soiled linens were placed on top of a trashcan in the resident's room, and the mechanical lift was wheeled to a common area after use, raising concerns about environmental contamination. Additionally, staff were observed providing pericare to a resident with dementia and incontinence without changing gloves or sanitizing hands between dirty and clean tasks. Interviews with the Infection Preventionist, Director of Nursing, and other nursing staff confirmed that facility policy requires glove changes and hand hygiene between tasks and after glove removal, as well as disinfection of equipment between residents. These lapses were inconsistent with the facility's own infection control policies and standard precautions.