Hand hygiene was not performed during incontinence care for two residents when CNAs moved from contaminated tasks to clean tasks. One CNA and two CNAs handled soiled briefs and fecal matter, then continued with clean diapering, repositioning, and contact with clean resident items without changing gloves or performing hand hygiene. The CNA supervisor, DON, and Administrator acknowledged the issue.
Hand hygiene was not performed while a CNA passed ice to residents. The CNA wore the same gloves from one resident room to another, dumped water, placed ice in pitchers, wiped bedside tables, and exited rooms without sanitizing or washing hands after glove removal. The CNA stated hand hygiene should have been done after removing gloves, and the DON stated hands should be washed or sanitized before gloving and between residents.
A CNA provided incontinence care to a resident with overactive bladder and constipation, but after wiping feces from the resident’s buttocks, she did not remove her soiled gloves or perform hand hygiene before handling a clean brief and touching the resident’s clothing and bedsheets. The CNA confirmed the lapse, and the DON stated staff were expected to change gloves after cleaning feces and before touching clean items.
Unlocked Biohazard Waste Closet: The facility failed to maintain its infection prevention and control program when the biohazard waste storage closet was observed unlocked and accessible to residents and the public, including several filled sharps containers. The Administrator later confirmed the biohazard door should remain locked and not be accessible to residents or the public.
The facility failed to maintain its infection prevention and control program when EBP signage was not posted outside the room of a resident with a tracheostomy and a resident’s yankauer suction was found stored in a bedside drawer without a plastic bag. Staff interviews confirmed the signage should have been posted and the suction should have been stored in a plastic bag and labeled.
Infection Control Lapse During Wound Care: A resident with a diabetic foot ulcer and multiple chronic conditions received wound care from a treatment nurse who failed to remove soiled gloves after removing the old dressing, reached into the clean field with contaminated gloves, cleaned the wound without changing gloves, and placed a soiled 4x4 into the clean field. The nurse confirmed the actions during observation.
Failure to Follow EBP During Resident Care: Staff did not wear required gown and gloves during high-contact care for multiple residents with EBP orders, including suctioning for residents with trachs and PEG tube care and a bed bath for residents with PEG tubes. PPE was available, EBP signage was posted, and the DON confirmed the staff should have used PPE; one LPN stated she did not know what EBP meant.
Staff failed to follow EBP during incontinent care for a resident with an EBP order when a CNA provided care without wearing a gown, despite PPE being available and an EBP sign posted. Staff also failed to sanitize hands during in-room meal service after assisting a resident up in bed, then continued serving other residents without cleaning hands; the CNAs confirmed the lapse and the DON agreed hand hygiene should have been performed.
Infection Control: Failure to Use Required PPE and Hand Hygiene During EBP Care. Staff did not follow EBP precautions for two residents with devices, including a resident with a suprapubic catheter and a resident with a PEG tube. During observed care, CNAs and an LPN failed to perform hand hygiene, changed gloves improperly, and did not don gowns during high-contact care and device care, despite EBP signs and orders being in place.
Failure to implement EBP occurred when a resident with a central line was not placed on EBP per facility policy. Staff provided high-contact care, including transferring and changing clothing, while wearing gloves only and no gown, and both the DON and IP confirmed the resident had not been placed on EBP despite having an indwelling medical device.
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