Failure to Follow Hand Hygiene During PEG Dressing Change and Inadequate UTI Surveillance
Penalty
Summary
The deficiency involves failure to follow infection prevention and control practices during a dressing change and inadequate infection surveillance for UTIs. During observation of wound care for Resident #20, who had multiple diagnoses including ALS, severe cognitive impairment (BIMS score 0), dependence for nearly all ADLs, and a stage 4 sacral pressure ulcer, an RN performed a PEG tube dressing change without proper hand hygiene. After removing the soiled dressing with gloved hands, the RN did not remove the soiled gloves, perform hand hygiene, and don clean gloves before cleansing the PEG stoma. Instead, the RN cleansed the site while still wearing the soiled outer gloves, then removed them to reveal a second pair of gloves underneath, and proceeded to apply a clean dressing. The RN confirmed this sequence of actions after the procedure. Facility policies titled "Dressing Change-Clean" and "Handwashing" required staff to remove and dispose of gloves and wash hands thoroughly after removing a soiled dressing, and to wash hands before and after contact with resident bodily fluids, indwelling lines, resident equipment, soiled linen, specimen collection, or general cleaning. These policies were confirmed by an LPN during interview. The observed practice during the PEG tube dressing change did not follow these written policies, as the nurse did not remove the soiled gloves and perform hand hygiene before cleansing the site and applying a new dressing. The facility also failed to conduct effective infection surveillance for UTIs. Review of infection control surveillance logs showed that in January 2026 the west wing had seven UTIs and the east wing had two, compared to three total UTIs in December 2025, all on the west wing. Three of the seven January west wing UTI cases lacked an identified organism on the surveillance log and were entered as "unknown" based on ER diagnoses and antibiotic orders. Room mapping for January showed multiple residents with UTIs in close proximity, including multiple residents in the same rooms and nearby rooms. The newly appointed infection preventionist reported she had been in the role for four weeks, had not yet investigated or monitored infection trends for January or February, and was still learning the program. A regional nurse and a newly hired RN were only beginning to review the logs for trends, and QAPI meeting minutes from the prior quarter documented multiple nosocomial infections without identifying problems, trends, or action plans related to those infections.
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