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.
Failure to Follow EBP During G-Tube Medication Administration: A resident with an indwelling catheter and feeding tube was on EBP, with orders and a care plan requiring gown and glove use for high-contact care. During G-tube medication administration, an LVN used gloves but did not don a gown, and the LVN’s sweater touched the resident’s bed while disconnecting the feeding tubing and preparing medication. The LVN, IP, and DON all confirmed that gown and gloves were required for this type of direct care.
Failure to Follow PPE and Glove Change Requirements During Wound Care: An LPN did not wear the required gown for EBP and did not change contaminated gloves or perform hand hygiene while providing wound care to a resident with a stage 4 sacral pressure ulcer. The resident’s care plan and order required EBP, and facility policy directed staff to use PPE and change gloves during wound care.
A resident with MRSA colonization and a PICC line for IV antibiotics experienced multiple breaches in infection control by nursing staff. An LPN repeatedly double-gloved, handled room surfaces, trash can lids, and the medication cart, then donned new gloves without performing hand hygiene before preparing and administering oral and IV medications. During PICC access, the LPN wiped the access port for only a few seconds, allowed IV tubing to touch bedding, let the access port fall onto the resident’s arm, and then re-accessed the line without hand hygiene or glove changes. At another time, the PICC site was left uncovered while a treatment nurse prepared for a dressing change, and the LPN entered without prior hand hygiene, disconnected IV tubing, and flushed the line after only a brief alcohol wipe. Staff interviews showed uncertainty and inconsistency regarding required scrub times, glove use, and dressing change schedules, which conflicted with facility policies and stated expectations for aseptic PICC care and hand hygiene.
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