Failure to Follow Infection Control Policies During Resident Care
Penalty
Summary
The facility failed to implement its infection prevention and control policies in several instances involving both incontinence and wound care. In one case, a nurse aide provided incontinence care to a resident and left a soiled brief on the resident's nightstand for approximately 45 minutes, rather than disposing of it immediately in a trash bag as required by policy. The aide acknowledged she intended to return with a bag but did not do so until prompted. Facility leadership confirmed that the brief should not have been placed on the nightstand and that the surface should have been disinfected after the incident. In another instance, a nurse failed to follow proper hand hygiene and personal protective equipment (PPE) protocols while providing ostomy and wound care to a resident on enhanced barrier precautions. The nurse did not don a gown as required, used bare hands to measure the resident's stoma and apply the ostomy appliance, and failed to clean scissors after use. During wound care, the nurse did not consistently wash hands between glove changes and reached into a package of gauze with contaminated gloves, later discarding the remaining gauze. The nurse also did not always wash hands before donning new gloves during the procedure. Interviews with facility staff, including the unit manager, DON, and infection preventionist, confirmed that the observed actions were not in compliance with facility policies regarding regulated medical waste, standard precautions, hand hygiene, and enhanced barrier precautions. The staff involved were aware of the policies but did not adhere to them during the observed care activities.