Failure to Adhere to Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple instances of non-compliance with hand hygiene and personal protective equipment (PPE) protocols during resident care. In several observed cases, certified nursing assistants (CNAs) did not perform hand hygiene before donning gloves or between glove changes while providing incontinent care. Gloves were sometimes taken from personal pockets, which staff acknowledged could be contaminated due to contact with personal items such as keys and cell phones. During care, gloves were not changed after cleaning soiled areas and before handling clean briefs, and hand hygiene was not performed between glove changes. A licensed vocational nurse (LVN) failed to wear a gown while administering medication via a gastrostomy tube to a resident who had an order for enhanced barrier precautions (EBP), despite signage indicating the requirement for gown and glove use. The LVN acknowledged awareness of the EBP requirement but did not follow the protocol during the observed medication administration. The resident in question had a feeding tube and severe cognitive impairment, and the care plan specified the need for enhanced barrier protection. Additional observations included a CNA not changing gloves or performing hand hygiene while providing incontinent care to a resident with Alzheimer's disease and muscle wasting. The CNA also carried a package of wipes between resident rooms, which was identified as a potential source of cross-contamination. Facility policies required hand hygiene before and after resident contact, after removing gloves or PPE, and after contact with bodily fluids or contaminated equipment. The facility's infection control policies also specified the use of gowns and gloves for residents with indwelling medical devices or feeding tubes. Despite these policies, staff did not consistently adhere to infection control protocols during the observed care activities.