Failure to Follow Infection Prevention and Control Protocols During Resident Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were followed during care for three residents. For one resident with multiple diagnoses including hemiparesis, diabetes, and a stage three pressure ulcer, an LPN performed wound care without performing hand hygiene between glove changes and used scissors from her pocket without cleaning them before cutting gauze that was placed in the resident's sacral wound. Both the LPN and the infection control nurse confirmed these lapses during an interview, and facility policy required infection prevention during wound management. Another resident with severe cognitive impairment, incontinence, and a feeding tube was under Enhanced Barrier Precautions (EBP) per physician order. During incontinence care, a CNA wore gloves but did not change them between tasks, did not wear a required gown, and failed to perform hand hygiene after glove removal and before leaving the room to obtain additional supplies. The CNA acknowledged these failures during an interview, and facility policy required handwashing after glove removal and after contact with potentially contaminated items. A third resident with Huntington's disease and a feeding tube also required EBP. An RN administered medications and water flushes through the resident's g-tube while wearing gloves but did not wear a gown as required. The RN stated she was unclear about the PPE requirements for this procedure, and the infection preventionist confirmed that both gown and gloves were required. Facility policy and posted signage indicated that EBP, including gown and gloves, should be used for high-contact care activities.