F0880

E

Inadequate Infection Control Practices and EBP Implementation

Kingsville, Texas Survey Completed on 03-25-2026

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, glove use, and implementation of Enhanced Barrier Precautions (EBP). For one resident, a female with a history of cerebral infarction and type 2 diabetes with hyperglycemia, the care plan identified risk for skin breakdown related to bladder incontinence and dependence in toileting hygiene, with interventions to check for incontinence and clean the perineal area with each episode. During observed incontinent care, two CNAs gathered clean supplies into a clean bag and placed an open trash bag on the resident’s bed for soiled items, then donned gloves after hand hygiene. While removing the resident’s brief, feces were smeared down the resident’s leg. One CNA cleaned the resident’s front and, without performing hand hygiene or changing gloves, accessed the clean supply bag and handed clean supplies to the other CNA, who was cleaning feces from the resident’s backside and between the legs.

During the same episode of care, one CNA manipulated the trash bag on the resident’s bed with soiled gloves after dirty gloves had fallen out of the bag onto the bed, placing the soiled gloves back into the bag and pulling the sides of the bag up before returning to incontinent care. After care was completed, one CNA performed hand hygiene in the bathroom while the other CNA fastened a clean brief and pulled up the resident’s clothing without first performing hand hygiene. That CNA then performed hand hygiene and immediately grabbed and tied the trash bag containing soiled items with bare, clean hands and carried it out of the room. In subsequent interviews, both CNAs acknowledged that they should have performed hand hygiene and changed gloves when moving from dirty to clean areas, should not have handled clean supplies with soiled gloves, and should not have handled the trash bag that had been manipulated with dirty gloves using bare, clean hands. The facility’s hand hygiene and perineal care policies required proper hand hygiene and glove changes when soiled, and specified that gloves do not replace hand hygiene.

The deficiency also includes failure to ensure appropriate PPE availability and implementation of EBP for two other residents. One male resident with osteomyelitis, local skin and subcutaneous tissue infection, type 2 diabetes, and an active wound infection had physician orders and a care plan for EBP due to diabetic ulcers, requiring gown and gloves for high-contact resident care activities each shift. Another female resident with a displaced trimalleolar fracture and a surgical incision had physician orders and a care plan for EBP due to the surgical incision, with interventions including posting an EBP sign on the door and using gown and gloves for specified high-contact activities, and mask or eye shield as indicated. Observation revealed that these residents’ rooms did not have PPE immediately outside or near the rooms; only one PPE cart was located toward the ends of each hall. A CNA stated that EBP signs were used to indicate when PPE should be worn for certain activities and that PPE was usually located in a bin outside residents’ rooms, but she was unsure where PPE for one resident was and noted PPE was available in the shower room on the hall.

In an interview, the DON, who also served as the infection control nurse, stated that hand hygiene should be performed when going from dirty to clean areas but asserted that CNAs could grab the outside of the trash bag with clean, ungloved hands because the outside was considered clean. The DON further stated that EBP was used for residents with wounds or indwelling devices and that EBP rooms did not need PPE outside the rooms as long as it was available on the hall or close by. She indicated that for EBP only gowns and gloves were required for high-contact activities, that face shields and goggles were not used for EBP even for splash back, and that if such eye protection were needed she would place the resident on droplet precautions. She also stated that residents with a known or colonized CDC-targeted MDRO would be placed on contact precautions rather than EBP. CMS and CDC guidance, as well as the facility’s own EBP policy, required that gowns and gloves be made available near or outside the resident’s room and that clear signage and ready access to PPE be ensured when implementing EBP.