Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by direct observations of staff not following established protocols during resident care. One certified nursing assistant (CNA) did not perform hand hygiene or change soiled gloves during incontinent care for a female resident with severe cognitive impairment, hypertension, diabetes, and dementia. The CNA also used supplies stored on a dirty linen cart and failed to wash hands or use sanitizer after completing care, returning contaminated items to the cart. The CNA acknowledged awareness of proper procedures but attributed the lapse to nervousness during survey observation. Additionally, a registered nurse (RN) did not change gloves or perform hand hygiene while replacing feeding tube supplies for a male resident with cerebral vascular disease, aphasia, dysphagia, and hypertension. The RN wore personal protective equipment but moved between contaminated and clean tasks without changing gloves or sanitizing hands, and left the room without performing hand hygiene. The facility's infection control policy requires handwashing after direct resident contact, after removing gloves, and after handling potentially contaminated items, but these procedures were not followed during the observed care. Interviews with staff and the Director of Nursing (DON), who also serves as the infection control preventionist, confirmed that staff had recently received in-service training on infection control, including glove changes and hand hygiene. Despite this training, staff did not adhere to the required protocols during care, as observed by surveyors. The DON acknowledged the importance of these practices and that failure to follow them could result in the spread of germs.