Infection control practices were not consistently followed during resident care. Staff were observed failing to wear required gown and gloves for EBP care, not cleaning a glucometer after use, not removing gloves or sanitizing hands between tasks, and handling soiled linen in an unbagged manner. A resident with ESBL E. coli UTI had conflicting precaution status and lacked clear documentation for contact precautions or EBP, and the facility had not completed its annual IPCP review.
Infection Control Program and Hand Hygiene Failures: During lunch service, a CNA wiped a resident’s nose with gloves, removed the gloves, and then put on a new pair to feed the resident without sanitizing her hands. The DON acknowledged the hand hygiene issue and stated she was unaware that the facility’s IPCP policies needed annual review, despite policy language requiring review at least annually.
PPE use was not followed for a resident on Contact Precautions for ESBL in the urine. An RN entered the room wearing gloves, placed a diabetic testing supply caddy on the resident’s bed, and obtained a blood glucose reading before exiting and removing gloves. The Contact Precautions sign directed staff to wear gloves and gown for all care and resident contact, and the Unit Manager confirmed PPE was required during blood glucose checks and that the supply caddy should not have been placed on the bed.
Failure to Complete Annual IPCP Review: The facility did not complete an annual review of its IPCP. During record review, infection control policies for hand hygiene and standard and transmission-based precautions lacked evidence of being developed, implemented, reviewed, or revised as required. The DON was initially unable to provide the policies and later confirmed that the facility had not conducted an annual review of its IPCP.
Infection Control Failure During Pressure Ulcer Dressing Change: An RN performed a wound dressing change for a resident with a Stage 3 heel pressure ulcer while using poor infection control practices. The RN contaminated a clean work field by handling the treatment cart, keys, and wound camera with the same gloves, then continued the procedure with soiled gloves while applying the dressing. The RN also did not follow the EBP sign outside the room by not wearing a protective gown during the wound care.
Failure to Follow Enhanced Barrier Precautions During Wound Care: A resident had an unstageable pressure ulcer on the spine, and the care plan required EBP with gloves and a gown for wound care. During an observed dressing change, an RN completed the procedure without wearing a gown, and later confirmed the finding in interview.
Failure to Follow Contact Precautions for C-diff: A resident with C-diff was on Contact Precautions, with PPE available and signage posted at the room entrance. Surveyors observed an LSW in the resident’s room without a gown or gloves, and the RN Mgr stated PPE was only needed if touching items before later correcting the staff member. The facility policy required PPE to be worn before or upon entry for residents on Transmission Based Precautions, including C-diff.
Infection control failures were observed involving EBP, PPE, and urinal handling. A resident with an indwelling catheter and another resident with a catheter had no EBP signage posted, an LPN performed trach care for a resident with chronic respiratory failure and a tracheostomy without face protection, and two unlabeled urinals were found hanging in a shower room.
The facility failed to complete an annual review of its ICP and did not document any update or revision of the program. The IP stated she did not know whether the ICP had been reviewed, and the Administrator confirmed that no annual review had been completed.
The facility failed to implement and support an effective infection prevention and control program when a resident on contact precautions for ESBL in the urine was cared for by an LPN who entered and exited the room to administer medications without donning required PPE, despite posted instructions and available supplies. Staff interviews revealed misunderstanding of when gowns and gloves were required and lack of familiarity with EBP, with a CNA stating the facility does not use EBP and that PPE is not needed if direct care is not provided. Review of the infection control manual showed no written EBP policies, and the DON acknowledged she had assumed EBP were in place but was unaware they were not included in the manual.
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