Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to implement infection control standards during resident care, as evidenced by observations involving two residents. For one resident with chronic kidney disease, necrotizing fasciitis, and Fournier gangrene, a wound nurse was observed touching a trash can with gloved hands and then proceeding to perform wound care without changing gloves or sanitizing hands. Additionally, after handling a soiled colostomy bag, the nurse changed from soiled to clean gloves without performing hand hygiene in between, contrary to the facility's hand washing policy which requires hand washing after handling contaminated objects and after removing gloves. In a separate incident, a certified nurse assistant provided incontinence care to another resident with metabolic encephalopathy, COPD, diabetes, and vascular dementia. During care, the CNA changed contaminated gloves but did not perform hand hygiene before immediately donning new gloves to continue care. This action was also inconsistent with the facility's hand washing policy, which specifies that hands should be washed after removing gloves. Both staff members confirmed these practices during interviews.