Failure to Follow Infection Control Guidelines During Resident Care
Penalty
Summary
The facility failed to follow appropriate infection prevention and control guidelines for six of eight residents reviewed, specifically in the areas of perineal care, bathing, and isolation procedures. Multiple observations revealed that staff did not consistently perform hand hygiene before and after resident care, including after removing gloves, handling soiled linens, and exiting isolation rooms. For example, a CNA was observed entering a resident's room without hand hygiene, placing soiled linens on the floor, and later handling clean items and using the nurse's station phone without washing hands. Another CNA removed PPE outside of the resident's isolation room and failed to perform hand hygiene before entering another resident's room. Additional deficiencies were observed during bathing and incontinence care. Staff were seen not washing hands before donning gloves, not performing hand hygiene between glove changes, and handling soiled items without gloves or hand hygiene. In several cases, staff handled clean linens and resident clothing after contact with soiled materials, and in one instance, a towel used to clean a hallway spill was handled with bare hands and then brought to the soiled utility room without hand hygiene. These lapses occurred despite the facility's policies and staff training materials specifying the need for hand hygiene at key moments during resident care. The residents involved had complex medical histories, including severe cognitive impairment, hemiplegia, chronic kidney disease, diabetes, and active infections requiring isolation precautions. Care plans for these residents required frequent assistance with activities of daily living, including toileting and bathing, and in some cases, enhanced barrier precautions or isolation due to infectious conditions. Despite these requirements, staff did not adhere to established infection control protocols, as confirmed by interviews with staff and review of facility policies.