Inconsistent Infection Control Practices and PPE Use
Penalty
Summary
Surveyors observed multiple failures in infection prevention and control practices across five of six facility halls. Residents on contact precautions were not consistently identified with appropriate signage, and staff did not always use required personal protective equipment (PPE) when entering rooms of residents on contact precautions. For example, staff were seen entering rooms of residents with C. difficile and other transmissible infections without donning gowns or gloves, and some staff believed PPE was only necessary during close care, contrary to facility policy. Additionally, contact precaution signs were missing or obscured on some doors, and staff were unclear about which residents required precautions. Improper storage of medical and personal care equipment was also noted. Nebulizer and oxygen masks were left uncovered on bedside tables without appropriate storage bags, and an open, unlabeled water bottle with a used washcloth was found on a hallway railing. Linen carts intended for clean linen storage contained inappropriate items such as bottles of cleaner, pens, air freshener, perineal/body wash, and an open can of soda, which staff acknowledged should not be stored with clean linen. Interviews with staff confirmed a lack of understanding and inconsistent application of infection control policies, particularly regarding when to use PPE and how to store equipment and supplies. Staff also reported confusion between contact precautions and enhanced barrier precautions, and acknowledged that education on infection control may not be clear enough. Facility policies reviewed by surveyors outlined requirements for signage, PPE use, and storage practices, but these were not consistently followed in practice.