Infection Control Failures: Equipment Disinfection, Hand Hygiene, and PPE Use
Penalty
Summary
Surveyors observed multiple failures in the facility's infection prevention and control practices. Staff did not disinfect a mechanical lift after use between two residents. Specifically, after transferring one resident from a wheelchair to a bed, the mechanical lift was pushed into the hallway without being sanitized. Later, another staff member used the same lift to transfer a different resident without disinfecting it before or after use. Additionally, during perineal care for a resident with Alzheimer's disease and incontinence, a CNA failed to perform hand hygiene or change gloves after handling a trashcan and before providing direct care, contrary to facility policy. The resident required extensive assistance with personal care and was always incontinent of bowel and bladder. Further, a CNA failed to remove PPE before exiting a room where both residents were on Enhanced Barrier Precautions due to invasive devices. The staff member exited the room wearing a gown and walked to another unit, which was not in accordance with the facility's policy that requires gowns to be discarded in the room. Staff interviews confirmed knowledge of the correct procedures, but the observed actions did not align with established infection control policies.