Failure to Adhere to Infection Prevention and Control Practices
Penalty
Summary
The facility failed to maintain professional infection prevention and control practices for three residents. For one resident with moderate cognitive impairment and a PICC line, an LPN entered the room, performed care involving the resident's antibiotic and PICC, removed gloves, and then touched multiple surfaces in the facility without performing hand hygiene. Both the LPN and the Nursing Home Administrator confirmed that hand hygiene should have been performed after glove removal, as required by facility policy. Another resident, who was cognitively impaired and had an indwelling urinary catheter, did not have Enhanced Barrier Precautions (EBP) in place as required. Observations over several days showed that there was no signage or PPE station indicating EBP in or near the resident's room, despite the care plan stating that EBP was in effect. Staff interviews confirmed that EBP should have been implemented for this resident due to the presence of the indwelling catheter, but it was not. A third resident was observed during a medication pass when an LPN obtained a blood sugar reading while wearing gloves. After removing the gloves and washing hands, the LPN turned off the faucet with her clean hand instead of using a paper towel, contrary to facility policy. Both the LPN and the Director of Nursing acknowledged that the correct procedure was not followed. These findings demonstrate lapses in adherence to established infection prevention and control protocols.