Failure to Follow Infection Control Procedures During Resident Care
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices affecting three residents. For one resident with dementia, dysphagia, and an ostomy, Enhanced Barrier Precautions (EBP) were ordered, requiring the use of gloves and gowns during high-contact care. Despite an EBP sign on the door, staff were observed changing the resident’s leaking ostomy bag while only wearing gloves, not gowns as required. The resident’s hospital gown was stained and wet from the leak, and the call light was out of reach, with the resident reporting not being changed in two days. The unit manager acknowledged not wearing a gown during the procedure, contrary to facility policy. In another instance, two CNAs provided incontinence care to a resident with diabetes and myelitis without cleaning the bedside table or placing a barrier before setting down supplies. During care, a pack of wipes was placed directly on the resident’s bed, and one CNA changed gloves without performing hand hygiene. For a third resident with a history of sepsis and multiple comorbidities, an LPN performed wound care without cleaning the bedside table or using a barrier before placing supplies, which was confirmed in interview. These actions were inconsistent with the facility’s infection control policies, which require hand hygiene, proper glove use, and clean surfaces or barriers for supplies during resident care.