An LPN failed to perform hand hygiene before, after, and between medication administrations while passing medications to multiple residents. The LPN was observed handling resident medication cups, assisting a resident with medications, and touching a hallway trash can lid before returning to the med cart without cleaning hands. Facility interviews and policy review confirmed that hand hygiene is required before and after resident contact, between residents, and after contact with contaminated items.
Infection control practices were not followed when an MDS Coordinator administered prescribed eye drops to a resident on contact isolation. The MDS Coordinator entered the room without PPE, handled a tissue near the resident’s face, discarded it, and left without sanitizing hands. The resident had CRAB wound infection, pressure ulcers, and paraplegia, and the room displayed contact isolation signage. The MDS Coordinator said she believed the resident was on EBP rather than contact isolation, while the IP and DON stated staff were expected to use the PPE indicated by the signage and perform hand hygiene before leaving the room.
A resident on ESBL contact isolation had PPE available outside the room, but no biohazard disposal containers were in the room when staff entered. A CNA entered without PPE, then handled the resident’s brief and shredded material and placed them in a regular trash can. A laundry worker also entered the resident’s room without hand hygiene or PPE while moving laundry. In the laundry area, the handwashing sink was obstructed, and staff gave inconsistent accounts of hand hygiene and contact precaution practices.
A resident with a PICC line, IV antibiotics, and an open wound was not properly identified for EBP, and the room lacked the required door signage and PPE supplies when observed. Staff interviews showed they understood EBP should be posted for residents with indwelling devices, but the resident was missing from the facility EBP list and a staff member later transferred the resident without appropriate PPE. An LPN also administered IV antibiotics through the PICC line without donning PPE before the procedure.
Improper Infection Control During Medication Administration: A MAC administered oral meds to a resident with DM, dementia, and HTN after one pill fell to the floor. The MAC picked up the pill with bare hands, returned it to the cup, and gave the meds without hand hygiene. RNs, the DON/IP, and the Administrator stated that a dropped medication should be discarded and hand hygiene performed before continuing, and facility policy required hand hygiene before handling meds.
A resident with a feeding tube, severe cognitive impairment, cerebral palsy, Lennox-Gastaut syndrome, and dysphagia was on EBP per the care plan. Although EBP signage and PPE were available in the room, a CNA transferred the resident from a wheelchair to bed without wearing a gown. Staff interviews showed they understood EBP requirements for residents with feeding tubes, and the DON stated proper PPE was expected when required.
An LPN administered medications through a resident’s PEG tube while wearing gloves but not a gown, despite EBP orders, the care plan, and PPE available at the room entrance. The resident had stroke, dysphagia, critical illness myopathy, and moderate cognitive impairment. Interviews with staff and leadership confirmed that gloves and a gown were required for feeding tube care under EBP, and the facility policy stated gowns and gloves are required during high-contact care activities, including feeding tube care.
Surveyors found that a nurse responsible for wound care and infection prevention failed to follow basic infection control practices while treating two residents with pressure ulcers and one with a suprapubic catheter. The nurse repeatedly handled keys, a phone, and a computer, then accessed and prepared wound supplies without performing hand hygiene, touched gauze with ungloved hands before using it on a wound, and set up supplies on non‑impervious paper towels next to personal items instead of on a properly disinfected, protected surface. During one observation, the nurse cleaned a hip pressure ulcer and then a suprapubic catheter site using separate gauze cups but without changing gloves or performing hand hygiene between dirty and clean tasks, and then applied dressings after glove removal without washing hands. Facility policies required clean technique, use of an impervious barrier, handwashing between dirty and clean steps, and labeling dressings, but these were not followed, and the nurse and leadership acknowledged that the nurse had not received formal wound care training from the facility.
Improper PPE Use During EBP Care: Staff failed to wear required gown and gloves while providing direct care to a resident on EBP for an indwelling catheter. A CNA was observed dressing the resident without proper PPE, and an RNS was later observed assisting with a mechanical lift transfer without proper PPE. The resident had an indwelling catheter, a UTI history, and ESBL-related catheter orders, and the facility policy identified dressing and transferring as high-contact activities requiring PPE.
An LPN performed wound care for a resident with pressure ulcers and changed gloves during the procedure without performing hand hygiene between glove changes. The resident had diagnoses including Parkinson’s disease, psychotic disorder, and pressure ulcers, and required substantial to maximal assistance with personal care. The DON and Administrator stated hand hygiene should be performed with each glove change, and the facility policy required washing hands after removing gloves.
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