Failure to Adhere to Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by multiple instances where staff did not adhere to established infection control protocols during resident care. Certified Nursing Assistants (CNAs) were observed not performing hand hygiene at critical points, such as after glove removal, during incontinence care, and before leaving resident rooms. In several cases, CNAs changed gloves without performing hand hygiene, and in some instances, did not use the required personal protective equipment (PPE), such as gowns, when providing care to residents on Enhanced Barrier Precautions due to the presence of indwelling medical devices or wounds. Specific observations included a CNA failing to perform hand hygiene during and after incontinence care for a male resident with a history of femur fracture and mild intellectual disability, and not cleaning all necessary areas during care. Another CNA did not don a gown while caring for a male resident with Parkinson's disease and a urinary catheter, and failed to perform hand hygiene at multiple points during catheter and incontinence care. Additional deficiencies were noted with a female resident with diabetes and a history of thrombosis, where a CNA did not perform hand hygiene after assisting with a mechanical lift transfer and before leaving the room. Similar lapses were observed with a female resident with candidiasis, dementia, and a urinary tract infection, where the CNA did not use a gown, failed to change gloves appropriately, and did not perform hand hygiene after care. Further, during care for a male resident with primary lateral sclerosis and neuromuscular bladder dysfunction, two CNAs failed to perform hand hygiene after glove changes and before leaving the room, despite handling urinary drainage bags and providing incontinence care. Interviews with the involved CNAs and supervisory staff confirmed awareness of the required protocols, including hand hygiene and PPE use, but revealed lapses in practice, often attributed to forgetfulness or oversight. Facility policy required Enhanced Barrier Precautions for residents with wounds or indwelling devices, but these were not consistently followed during observed care activities.