F0880

E

Failure to Implement Infection Control Practices for EBP, Device Care, Wound Care, and Shared Equipment

Dover, Ohio Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), device and wound care practices, and cleaning and disinfection of shared equipment. For a resident with type 2 diabetes mellitus and a urinary tract infection receiving IV meropenem via a PICC line, an LPN administered the medication without donning a gown, despite an EBP sign on the door and a facility policy requiring gown and gloves for high-contact care involving central lines. The LPN confirmed she had not implemented EBP and stated she had never been told it was required. The facility’s EBP policy, revised March 2024, required gown and glove use for high-contact resident care activities, including device care such as central lines, and indicated EBP for residents with indwelling medical devices regardless of multidrug-resistant organism colonization.

Another deficiency occurred during wound care for a resident with peripheral vascular disease and chronic obstructive pulmonary disease who had wounds on the left toe and coccyx and a care plan intervention for EBP, including wearing a gown and gloves when providing care. A physician’s order directed daily and as-needed dressing changes to the left third toe wound. During an observed dressing change to the lateral aspect of the third toe, an RN wore gloves but did not don a gown, despite an EBP sign posted on the door. The RN verified that the EBP sign was related to the resident’s wounds and acknowledged she had not worn a gown during the wound care. The same EBP policy requiring gown and glove use for high-contact resident care activities applied in this situation.

Additional infection control failures involved shared equipment and catheter care. For a resident with type 2 diabetes mellitus requiring daily blood glucose monitoring, an LPN used a shared glucometer, placed the glucometer and test strip container on the resident’s bed, then later on the medication cart and mouse pad, and did not clean or disinfect the glucometer or container after use before proceeding to administer medications to another resident. The LPN gave inconsistent answers about cleaning frequency and confirmed she had not cleaned the items after use, contrary to the facility’s policy requiring reusable items to be cleaned and disinfected between residents. In a separate observation, a CNA provided urinary catheter care to a resident with congestive heart failure, vascular dementia, and obstructive and reflux uropathy, then failed to remove gloves afterward and continued to handle the call light, bed controls, bedding, and the urinary collection bag and cover with the same contaminated gloves. The CNA confirmed she had not removed the gloves used for catheter care before touching these items.