The facility failed to follow infection control practices involving hand hygiene, glucometer disinfection, oxygen equipment storage, and linen handling. A CNA did not offer hand hygiene before a resident ate, nurses stored glucometers after wiping them with sanitizer or an alcohol swab instead of disinfecting them after each use, a resident’s nebulizer equipment was left uncovered, clean linens were transported with the cart cover not down, and PPE such as gowns and eyewear was not being used or available at the hoppers.
Hand hygiene and glove change practices were deficient when an RN performed a glucose finger stick on a resident with clean gloves, removed the dirty gloves, and put on clean gloves without performing hand hygiene. The resident had type 2 DM, HTN, and chronic pain syndrome. The IP stated hand hygiene should be performed when changing gloves and when moving from a dirty environment to a clean environment.
Infection control and hand hygiene practices were not followed during resident care for multiple residents. An LPN applied topical treatment and then handed a resident a mouth moisturizer without removing dirty gloves or cleaning hands, a CNA performed incontinence care and handled clean supplies without changing gloves or performing hand hygiene, and an RN began wound care after touching the bed controls and linens without being observed performing hand hygiene or changing gloves; enhanced barrier precautions were also not followed during wound care for one resident.
A facility failed to maintain infection control practices when residents in multiple rooms were served breakfast without being offered hand hygiene beforehand, despite a Dining Room policy requiring staff to encourage handwashing or sanitizing before each meal. A CNA later stated residents should have been offered hand hygiene and that staff are supposed to carry a large bottle of hand sanitizer to clean residents' hands.
The facility failed to maintain infection control practices for respiratory equipment and laundry handling. Two residents had nebulizer mouthpiece and tubing left uncovered on bedside tables, clean bed linens were observed being carried down the hallway uncovered, and staff stated the linens should have been bagged. In the laundry rooms, staff reported CNAs washed laundry and did not always use goggles or aprons, while multiple washers, dryers, vents, and surrounding surfaces had visible buildup. The DON and Administrator also stated there was no cleaning schedule for the personal washers or dryers.
Infection control practices were not followed when an LPN handled a glucometer and wound care supplies without proper hand hygiene or barrier protection, placed equipment and supplies on resident bedside tables, and returned a glucometer to storage without sanitizing it. An LPN also used dressing supplies from another resident during wound care and did not perform hand hygiene before or after glove changes. In addition, the Maintenance Director stated the facility had eight swamp coolers on the roof but had never tested them for Legionella.
Staff failed to consistently implement and follow Enhanced Barrier Precautions (EBP) during wound care for two residents. For a resident with an indwelling urinary catheter and an EBP order, an RN and a CNA removed their gowns after catheter care and performed a heel and toe dressing change wearing only gloves, despite a door sign requiring gown and gloves for wound care and other high-contact care. For another resident with multiple open leg wounds and active wound care orders, an RN and a nurse aide performed dressing changes with gloves only, without gowns, and there was no EBP signage or order in place. Interviews with nursing staff, the IP, and the DON revealed inconsistent understanding and application of the facility’s EBP policy, which requires gown and gloves for high-contact care activities, including wound care and device care, for residents with chronic wounds or indwelling devices.
A resident with COPD, heart failure, and an order for nightly CPAP use had the CPAP mask and tubing observed placed in the bed on top of the linen on two occasions. The facility’s policy required delivery devices to be kept covered in a plastic bag when not in use, but the equipment was not bagged. The DON stated the CPAP equipment should not have been in the bed and should have been stored appropriately and placed in a plastic bag when not in use.
The facility failed to implement its infection prevention and control program when a nurse provided incontinence and skin care to a resident with chronic conditions without performing hand hygiene between glove changes and while using double gloves, contrary to CDC and facility policy that gloves are not a substitute for hand hygiene. In a separate case, another resident with neurologic deficits and muscle weakness had an IV site with a transparent dressing that remained in place despite visible dried and wet blood beneath it after completion of IV antibiotics, contrary to CDC guidance and facility expectations that soiled IV dressings be changed.
A resident receiving IV meropenem via a PICC line for septic shock related to a UTI had an active care plan and door signage requiring enhanced barrier precautions, including use of gown and gloves for high-contact care and device care to reduce MDRO transmission. During an observed medication administration, an LPN performed hand hygiene, donned gloves, accessed and flushed the PICC line, and administered the antibiotic without donning a gown, later stating she had forgotten to do so. The IP confirmed that a gown was required before administering the antibiotic, and this failure created the potential for infection spread.
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