Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple staff members not following proper hand hygiene and personal protective equipment (PPE) protocols during resident care. Certified Nursing Assistants (CNAs) providing peri-care to a resident with bowel and bladder incontinence did not sanitize or wash their hands after removing soiled gloves and before donning new gloves. This occurred on more than one occasion with different CNAs, despite their acknowledgment during interviews that they were trained to perform hand hygiene between glove changes and understood the risk of cross contamination. Additionally, the Assistant Director of Nursing (ADON) did not use PPE or perform appropriate hand hygiene while providing wound care to a resident with multiple stage IV pressure ulcers. The ADON admitted to not changing gloves between wounds and not remembering if hand hygiene was performed. There was also no Enhanced Barrier Precautions (EBP) signage or PPE available at the resident's door, contrary to facility policy and CDC guidelines. The resident's wound was found uncovered for an extended period, and the ADON confirmed that dressings should be checked daily and reported if found off. Facility policy reviews revealed clear expectations for hand hygiene, PPE use, and EBP for residents with wounds or indwelling devices. However, observations and staff interviews demonstrated that these protocols were not consistently followed. The Director of Nursing (DON) and ADON both acknowledged the lapses in infection control practices, including the lack of PPE availability and signage, and the failure to ensure wounds were properly covered and monitored.