Infection Control Failures in PPE Use, Medication Handling, and Policy Review
Penalty
Summary
The facility failed to adhere to infection prevention and control protocols in several instances. One incident involved a staff member, the Director of Maintenance, entering a contact isolation room of a resident diagnosed with Clostridium difficile (C. Diff) without donning the required personal protective equipment (PPE). The staff member touched surfaces within the room, including the overbed table and the footboard of the resident's bed, with bare hands. The staff member later acknowledged not noticing the contact isolation signage and not wearing PPE as required. Facility policy specifies that staff must wear gloves and gowns when entering rooms under contact precautions, particularly for infections such as C. Diff. Another deficiency was observed during medication administration, where a registered nurse poured oral medications directly into her bare hands before placing them into a medicine cup and handing them to a resident. The nurse admitted to sanitizing her hands beforehand but recognized that medications should not be handled with bare hands. Facility policy requires that medications be dispensed without direct hand contact. Additionally, the facility failed to review and/or revise key infection control policies, such as those related to antibiotic stewardship and transmission-based precautions, on an annual basis as required by their own protocols.