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 two separate incidents involving staff not following established protocols. In the first incident, a certified nursing assistant (CNA) provided incontinent care to a female resident with kidney failure and incontinence. During the care, the CNA changed gloves multiple times without sanitizing her hands between glove changes, despite being aware that hand hygiene was required to prevent cross-contamination. The resident's care plan specifically required pericare after each episode of incontinence, and the facility's policy mandated hand hygiene after removing gloves. In the second incident, a licensed vocational nurse (LVN) disconnected an intravenous (IV) line from a male resident who had an infection related to a right knee prosthesis and was receiving antibiotics via a PICC line. The resident was under Enhanced Barrier Precautions (EBP), which required staff to wear both gloves and a gown during high-contact care activities, including device care. Despite signage outside the resident's room and physician orders indicating the need for a gown, the LVN only wore gloves and did not don a gown while disconnecting the IV. Interviews with staff, including the CNA, LVN, Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Administrator, confirmed awareness of the required infection control procedures. Staff acknowledged the lapses and recognized the importance of hand hygiene and gown use in preventing the spread of infection, as outlined in the facility's policies. However, these protocols were not followed during the observed care activities, resulting in deficiencies in infection prevention and control.