F0880

F

Infection Control, EBP, and Environmental Disinfection Deficiencies

Colorado Springs, Colorado Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, including proper hand hygiene, appropriate use of PPE, hygienic room cleaning, and adherence to chemical dwell times. Facility policies stated that hand hygiene is the primary means to prevent spread of healthcare-associated infections and is required before resident contact, before aseptic tasks, after contact with blood or body fluids, after touching a resident or their environment, and immediately after glove removal. Despite this, a registered nurse (RN) prepared and administered a subcutaneous enoxaparin injection to a resident without performing hand hygiene between handling the medication cart and administering the injection, and without donning gloves while breaking the resident’s skin. The RN only performed hand hygiene after exiting the room and after touching the medication cart computer. In another instance, while preparing famotidine for a different resident, the RN allowed a tablet that had fallen onto the top of the medication cart to be administered to the resident instead of discarding it.

Additional hand hygiene and aseptic technique failures were observed during tracheostomy care for a resident with a tracheostomy. The RN performed hand hygiene and donned clean gloves, but did not change gloves after removing the old inner tracheostomy cannula and before inserting the clean inner cannula. In interviews, the RN stated he did not know whether gloves were required for subcutaneous or intramuscular injections and reported he typically only wore gloves when manipulating an IV catheter. He also stated he did not know whether gloves should be changed between handling the soiled inner tracheostomy cannula and inserting the clean cannula, and that he had never considered the risk. The DON confirmed that hand hygiene should occur before dispensing and administering medications and after exiting the room, that gloves should be worn when breaking the skin for injections, that dropped pills should be discarded rather than administered, and that gloves should be changed after working with a dirty area such as a used tracheostomy cannula before moving to a clean area.

The facility also failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling devices and wounds during high-contact care activities. A resident with a tracheostomy reported that staff performing tracheostomy care wore gloves but never wore a yellow gown. During observed tracheostomy care for this resident, the RN performed hand hygiene and donned gloves but did not don a mask or yellow isolation gown, despite facility policy and CDC guidance indicating gown and gloves for device care such as tracheostomy care. In another observation, two CNAs and an RN provided high-contact care to a resident with a Foley catheter and a wound on the buttocks, including dressing, transferring with a sit-to-stand device, toileting, cleaning the resident’s bottom, and applying cream to the wound. They wore gloves but did not don EBP such as gowns during these high-contact activities. In interviews, a CNA stated she did not know of any special precautions for residents with tracheostomies, believed no residents were on EBP, and did not think special PPE was needed for dressing or toileting such residents. The RN involved in tracheostomy care stated he did not know what EBP were.

The infection preventionist stated that residents with indwelling lines or skin breakdown that increased infection risk would qualify for EBP and that EBP had been implemented in the past, but signage had been replaced during COVID-19 outbreaks and not brought back. The DON stated that residents with additional lines such as catheters or tracheostomies or skin breakdown would be expected to be on EBP and that there were several residents on EBP, but she was unclear about whether transferring required gowns under EBP. She also noted that EBP orders should be in place and care planned, and that door signs sometimes get switched and not replaced.

The facility further failed to follow manufacturer-recommended dwell times for disinfectant chemicals and to properly disinfect high-touch surfaces in resident rooms. Product information for NABC Concentrate required surfaces to remain wet for ten minutes, and Clean by 4D required treated surfaces to remain wet for a specified period for sanitization. Facility policy required following manufacturers’ instructions and cleaning horizontal surfaces daily and personal-use items at least twice weekly with disinfectant solution. During observations of two housekeepers cleaning resident rooms, both sprayed NABC Concentrate on toilets, sinks, counters, grab bars, and other bathroom surfaces and immediately wiped them dry, rather than allowing the required contact time. One housekeeper sprayed a rag with NABC to wipe a bedside table and used Clean by 4D on a grab bar, and the other used Clean by 4D on a side table, but in all instances the products were wiped off immediately.

In interviews, the environmental services director stated that the dwell time for Clean by 4D was two minutes and for NABC Concentrate was ten minutes, and that housekeepers were trained to spray surfaces first and let the chemicals sit while they completed other tasks such as trash removal and sweeping. She acknowledged that staff sometimes get in a hurry. She also stated that high-touch surfaces expected to be disinfected included light switches, door knobs, doors around the knobs, furniture and handles, bedside tables and legs, lamps, call lights, and chair arms. The infection preventionist stated that high-touch surfaces such as remotes, call lights, bedside tables, door knobs, phones, and bed rails should be sanitized daily and that chemical dwell times should be followed to clean off the spread of germs.