Failure to Implement Infection Prevention and Control Measures During High-Contact Care
Penalty
Summary
Facility staff failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in the use of enhanced barrier precautions (EBP) and personal protective equipment (PPE) during high-contact care for residents with wounds and indwelling devices. Observations revealed that staff did not consistently perform hand hygiene, wear gowns, or change gloves appropriately when providing wound care and catheter care. For example, a registered nurse and a licensed practical nurse did not wear protective gowns or perform hand hygiene between glove changes while changing dressings on a resident with chronic leg wounds and a catheter. The same staff touched their faces, handled contaminated items, and continued care without changing gloves or sanitizing hands, despite the resident's recent hospitalizations for wound infections and cellulitis. Another incident involved the facility's infection preventionist, who placed a resident's dirty sock on top of clean wound dressing supplies during a dressing change for a pressure ulcer. The infection preventionist continued the procedure without changing gloves or obtaining new supplies after contamination occurred. The director of nursing confirmed that staff were expected to change gloves and retrieve new supplies if contamination happened, but this protocol was not followed during the observed care. Additionally, staff failed to follow proper catheter care protocols for residents with indwelling urinary catheters. Observations showed that catheter bags were allowed to touch the floor, and staff did not wear isolation gowns or change gloves after handling potentially contaminated items such as trash cans before providing catheter care. Interviews with staff and the director of nursing confirmed awareness of the correct procedures, but these were not implemented during the observed care. These failures were noted for multiple residents who were dependent on staff for wound and catheter care.