Failure to Follow Infection Control Practices for Multiple Residents
Penalty
Summary
Facility staff failed to follow infection control practices for three residents. For one resident with a tracheostomy, a respiratory therapist was observed performing tracheostomy care without adhering to proper glove and hand hygiene protocols. The staff member donned clean gloves, touched potentially contaminated surfaces, and then proceeded to open sterile supplies and don sterile gloves over the soiled gloves. The staff member continued to provide care, including cleaning the stoma and replacing the inner cannula, without changing gloves or performing hand hygiene as required by facility policy and CDC guidelines. Another resident, who was totally dependent on staff for turning and positioning and had a diagnosis of paraplegia, was observed multiple times with a pillowcase containing a moderate amount of blood in contact with his leg. Despite these observations, staff did not offer to change the soiled pillowcase, and the resident reported that no staff member had offered to change it overnight. Interviews with nursing staff confirmed that a bloody pillowcase should not remain in contact with a resident due to infection control concerns. For a third resident with a physician's order for contact precautions due to shingles, staff failed to implement the required transmission-based precautions. During a transfer using a mechanical lift, staff wore gloves but did not wear gowns as required for contact precautions, and the signage on the resident's door indicated enhanced barrier precautions instead of contact precautions. Staff involved in the transfer stated they were unaware of the need for isolation precautions and did not wear gowns during the care activity.