The facility failed to maintain an Infection Control Program when dietary staff did not perform hand hygiene during a dining service observation and bedpans were found stored improperly in a shared bathroom. A dietary aide handled items for a resident after touching her glasses with gloved hands and another aide rubbed her eyes after removing gloves, then began putting on new gloves without sanitizing her hands. Surveyors also observed unlabeled, unbagged, and soiled bedpans placed on a shower chair, behind a grab bar, and on top of a plastic bag, with clean towels touching one of the bedpans.
A facility failed to maintain its infection control program when a CNA did not follow hand hygiene and PPE requirements while caring for a resident on EBP. The resident had left hip and foot wounds, a chronic Foley, and skin breakdown. During transfer and personal care, the CNA removed PPE, handled the resident and equipment with bare hands, transported the resident to the dining room, and later handled trash and a trash can lid without sanitizing her hands, despite policy stating gloves do not replace hand hygiene.
The facility failed to implement infection control measures for linen handling and EBP for residents with indwelling catheters. A covered linen/clothing rack was left uncovered in the hallway, and the DON stated the facility had researched EBP but was only using it for active infections, despite the infection prevention policy not including EBP procedures. Surveyors observed no EBP signage or PPE stations outside catheterized residents’ rooms, a catheter drainage bag on the floor, and staff members, including CNAs and an LPN, reporting they only used gloves and were unfamiliar with EBP. Residents with catheters, including one with a history of UTIs and MDROs, reported the same practice.
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.
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