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.
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.
Failure to Follow Hand Hygiene and EBP PPE Requirements: An LPN exited a resident’s room wearing gloves, touched the medication cart and a cup with the contaminated gloves, and re-entered the room without removing the gloves or performing hand hygiene. On another observation, a UM provided oral care and handled the resident’s G-tube without the required gown while the resident was on EBP; an enteral syringe with pink liquid was also present on the overbed table. The resident had a G-tube, urinary catheter, wound, and moderate cognitive impairment.
An LPN failed to maintain infection control during medication administration by reaching into her jacket pocket with a gloved hand to retrieve disinfectant wipes while cleaning glucometers for two residents with DM and hyperglycemia. The LPN said she kept the wipes in her pocket and did not realize she had put her gloved hand back into the pocket; the Clinical Operations Officer stated hand hygiene was expected at the appropriate times.
The facility failed to maintain its infection prevention and control program when a resident with shingles did not have transmission-based precaution signage posted and a CNA entered the room without the required PPE. The report also found that shared sinks serving two resident rooms were covered and unusable, and staff used a mechanical lift for multiple residents without disinfecting it between uses, despite policy and staff training requiring cleaning after each resident use.
Failure to Follow EBP PPE Requirements: A resident with a wound and EBP order was observed receiving direct care from a CNA who wore gloves but did not don the gown required by the room signage. The CNA handled a urine-filled bedpan, emptied and rinsed it, and later stated she did not know whether a gown was required or whether she had seen the signage. The DON and Administrator stated staff should wear the appropriate PPE, including gowns and gloves, for direct care under EBP.
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