Failure to Adhere to Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by multiple staff not adhering to established protocols for Enhanced Barrier Precautions and hand hygiene during care of three residents. In several observed instances, certified nursing assistants (CNAs) and a licensed vocational nurse (LVN) did not perform hand hygiene before or after resident care, did not change gloves between clean and dirty tasks, and failed to don required personal protective equipment (PPE) such as gowns when providing high-contact care to residents on Enhanced Barrier Precautions. These lapses were observed during incontinence care, dressing, mechanical lift transfers, and wound care. One resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, was on Enhanced Barrier Precautions due to a chronic eye infection. The assigned CNA did not perform hand hygiene before or after care, failed to wear a gown, and used the same gloves for both soiled and clean tasks, including handling the resident's clothing and wheelchair. Another resident, who was cognitively intact but required substantial assistance and had a colostomy and non-pressure wounds, also did not receive care in accordance with infection control protocols. The CNA providing care did not perform hand hygiene, did not wear a gown, and used the same gloves for incontinence care and handling personal items. Additionally, a CNA was observed leaving the resident's room and handling equipment in the hallway while still wearing PPE, only removing it outside the room. For a third resident, who was severely cognitively impaired, dependent for all care, and at risk for pressure ulcers, the LVN performing wound care did not change gloves or perform hand hygiene between cleaning multiple wounds, only doing so after all wounds were cleaned. The LVN later acknowledged not being aware of the need to change gloves and perform hand hygiene between wounds. Facility policies reviewed indicated that Enhanced Barrier Precautions and hand hygiene are required before and after resident contact, after glove removal, and when moving from soiled to clean tasks, but these protocols were not consistently followed by staff during the observed care.