Infection Control Breach During Wound Care: An RN and the SDC failed to follow aseptic technique during wound care for two residents. One RN placed supplies on an unclean bedside table, did not perform hand hygiene before donning PPE, left soiled dressings on the bed, reused contaminated gloves while touching the bed and resident, and reapplied a stained wrap. The SDC changed gloves during wound care but did not perform hand hygiene between glove changes while handling a soiled dressing. Facility policy, nursing standards, and staff interviews confirmed that hand hygiene, glove changes, and clean-field practices were expected during dressing changes.
Surveyors found infection control deficiencies in three shower rooms where clean linens were left uncovered on open shelving, shared resident equipment and personal belongings were stored in the bathing areas, and dirty linens and used items were present. The rooms contained multiple lifts, wheelchairs, shower equipment, slings, and other supplies, with some electrical equipment plugged in near water. Staff interviews confirmed the shower rooms were not intended for storage and that uncovered linens and mixed storage created unsanitary conditions and cross-contamination concerns.
An LPN handled a resident’s blister-pack medications with bare hands during medication pass and used bare hands to split a scored tablet before placing it in the medicine cup. The resident had a chronic infection of an internal knee prosthesis and was on enhanced barrier precautions. Facility staff, including the IP/ADON, DON, and Administrator, stated medications should be handled with sanitized hands and gloves, and the facility policy required hand hygiene and gloves when tablets were split.
Staff failed to follow infection control practices during resident care and medication administration. An LPN gave insulin to a resident on EBP without a gown, another LPN picked up a glove from the floor and used it during eye drop administration, and staff used shared and resident-specific equipment, including BP cuffs and a glucometer, without cleaning or disinfecting between uses. A resident’s Foley catheter bag was also observed touching the floor.
Failure to perform hand hygiene during medication administration. An KMA did not sanitize hands after each resident medication pass, picked up a dropped Risperidone tablet with bare hands instead of discarding it, and administered medications to a resident without hand washing or hand sanitizing before or after. Facility policy required hand hygiene and infection control procedures during medication administration, and leadership stated staff were expected to clean hands between residents.
The facility failed to follow infection control policies for three residents. A KMA administered eye drops without hand hygiene or gloves and handled another resident’s pills with an ungloved hand before giving the remaining medication. During wound care, an ADON/IP washed scissors in the sink and placed used scissors and tape back into the treatment cart drawer. The DON and Administrator stated staff were expected to follow infection control policies, including proper hand hygiene, glove use, and equipment handling.
Infection control procedures were not followed during laundry handling and wound care. Two staff members handling soiled linen said they only wore gloves and did not use gowns or aprons, and no aprons or gowns were available in the laundry room. During wound care for a resident with severe cognitive impairment and multiple diagnoses, an LPN set up a sterile field, then failed to remove gloves, perform hand hygiene, and don new gloves before starting treatment of the resident's left buttocks wound.
Shared resident equipment was not maintained in a clean and disinfected condition. Two Hoyer sit-to-stand lifts had visible debris and encrusted substance in the platforms, even though the facility policy and multiple staff, including an IP, DON, and Administrator, stated the lifts and other multi-use equipment were to be cleaned or sanitized after each resident use to prevent infection control and cross-contamination issues.
An LPN failed to sanitize her hands while serving meals and providing feeding assistance to three residents who required help with meals, and she used the same unsanitized hands between residents. She also drank from a personal cup at the table and rubbed her hand across her face before continuing resident care. The facility policy required hand hygiene before and after direct resident contact and before and after preparing or serving meals and drinks, and the DHS stated staff were expected to sanitize hands between residents and not eat or drink in resident care areas.
Failure to perform hand hygiene occurred during a medication pass when a CMA did not wash hands before giving meds to one resident or between giving meds to two residents. The CMA also handled medication and water cups on the cart, then used contaminated gloves while opening a gabapentin capsule. The ADON observed the event and addressed the CMA at the time.
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