Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
Staff failed to follow established infection prevention and control protocols during personal care for four residents, as observed and documented by surveyors. In multiple instances, certified nurse aides (CNAs) did not perform proper hand hygiene before donning gloves, after removing gloves, or between clean and dirty tasks. For example, a CNA provided incontinence care to a resident with an indwelling catheter without washing hands before or after glove use, and handled clean items such as briefs and ointment with soiled gloves. Similar lapses were observed with other residents, where CNAs applied creams, changed briefs, and touched various surfaces and resident belongings without changing gloves or performing hand hygiene between tasks. Additionally, staff did not adhere to facility policy regarding the handling of soiled linens. In one case, a CNA placed soiled washcloths and briefs on the resident's bed and later disposed of them without changing gloves or washing hands. In another instance, a soiled washcloth was thrown on the floor, and a plastic bag containing soiled wipes and gloves was tossed onto the hallway floor. These actions were inconsistent with the facility's policy, which requires soiled linens to be bagged at the point of use and handled with minimal agitation to prevent contamination. The residents involved had significant medical needs, including indwelling catheters, incontinence, and conditions such as spinal stenosis, diabetes, kidney failure, and dementia. They were dependent on staff for personal hygiene and toileting. Despite these vulnerabilities, staff did not consistently follow infection control standards, as confirmed by both observation and staff interviews. The Director of Nursing acknowledged that staff should perform hand hygiene before and after care, and that soiled linens should not be placed on the floor.