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 staff not adhering to required infection control practices during care of two residents. For one resident with a suprapubic catheter and wounds, who was under Enhanced Barrier Precautions (EBP) isolation, several staff members, including an LVN and three CNAs, provided care without wearing gowns as required for high-contact procedures. Observations showed that while gloves were used, gowns were not donned, and staff were unaware or forgot the necessity of this PPE despite the presence of a PPE supply cart outside the room. There was also no EBP isolation signage present. Interviews revealed that some staff did not know the purpose of the PPE cart or the need for gowns, and one staff member admitted to rushing and forgetting proper PPE due to time constraints. In another instance, during incontinent care for a different resident, a CNA failed to perform hand hygiene between glove changes, and an LVN placed dirty linen on the floor instead of in a designated plastic bag. The CNA acknowledged knowing the correct procedure but did not follow it due to nervousness, while the LVN stated that placing dirty linen on the floor was not an issue, despite facility policy requiring dirty linen to be bagged. The administrator and DON confirmed that staff were expected to perform hand hygiene before and after care, between glove changes, and to properly handle soiled linen, but these protocols were not followed during the observed care. Record reviews and staff interviews confirmed that the facility had policies in place for hand hygiene and EBP, requiring gowns and gloves for high-contact care and proper handling of soiled linen. However, the observed failures in PPE use, hand hygiene, and linen handling during resident care directly contradicted these policies and placed residents at risk for cross-contamination and infection, as acknowledged by staff and leadership during interviews.