Failure to Follow Infection Control Protocols During Device and Wound Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during care activities involving residents with indwelling medical devices and wounds. One LPN did not use appropriate personal protective equipment (PPE) when providing care to a resident with a PEG tube. Specifically, the LPN raised the resident's shirt and manipulated the PEG tube with bare hands before donning gloves to attach tube feeding, only performing hand hygiene after glove removal. This action was not in accordance with the facility's Enhanced Barrier Precautions policy, which requires targeted gown and glove use during high-contact care activities for residents with feeding tubes. In another instance, a CNA performed catheter care for a resident with an indwelling urinary catheter but failed to place wet wipes on a barrier and did not perform hand hygiene after removing gloves before donning a new pair. This was contrary to the facility's hand hygiene policy, which mandates hand hygiene before donning and after removing gloves. Additionally, the CNA placed trash bags directly on the resident's bed and disposed of them in the resident's trash, further deviating from infection control protocols. A separate observation involved an LPN providing wound care to a resident. The LPN removed a soiled dressing and cleansed the wound but did not perform hand hygiene after removing the soiled gloves and before donning new gloves to apply a clean dressing. The LPN also brought the treatment cart into the resident's room, contrary to facility policy, and failed to clean the cart's exterior after use. Interviews with the Director of Nursing confirmed that these actions were inconsistent with facility policies regarding PPE use, hand hygiene, and equipment handling during resident care.