An LPN administered medications through a resident’s PEG tube without donning a gown as required by the facility’s EBP policy for residents with indwelling medical devices. The LPN confirmed she forgot the gown, and the DON confirmed the gown should have been worn during the medication pass. The resident had severe cognitive impairment and a PEG tube.
Failure to Use EBP During Catheter Care: An RN changed a resident’s leaking catheter tubing and urine collection bag without wearing the required gown under EBP, despite a posted notice on the room door. Urine was observed on the floor and tubing was lying in urine, and the resident had an indwelling catheter with diagnoses including urinary retention, CKD, sepsis, neurogenic bladder, and UTI.
Infection control failed during peri-care for a resident with severe cognitive impairment and an order for EBP. Two CNAs did not perform hand hygiene before or during care, did not wear gowns, did not use a basin, reused the same soapy washcloth for multiple areas, and did not rinse soap from the resident’s skin before drying. Both CNAs acknowledged the care was not completed correctly, and the IP and RN stated the procedure did not follow facility policy.
Failure to follow infection control precautions involved two residents. One resident on contact isolation for ESBL did not have the required red biohazard barrel in the room, and contaminated PPE was discarded in a regular trash can. Another resident on EBP with a feeding tube had PEG site care performed by an LPN without hand hygiene or the required gown, and the LPN left the room wearing soiled gloves after discarding contaminated gauze on the bedside table.
Hand Hygiene Not Performed During Foley Catheter Care: A CNA provided foley catheter care to a resident with an indwelling urinary catheter and changed gloves multiple times without performing hand hygiene in between. The CNA acknowledged the missed hand hygiene, and the DON and Infection Preventionist stated that hand hygiene is required each time gloves are removed during invasive device care. The resident had anoxic brain injury, was in a vegetative state, and had an order for daily and PRN foley care.
A CNA failed to perform hand hygiene before, during, and after ADL care for a resident with trach status and dysphagia. The CNA entered the room without a gown, used the same gloves while adjusting the bed and handling the bed sheet, then continued care after contamination was observed with a urine-soiled brief and lift pad. The CNA later acknowledged the mistake, and the RN/IP and DON stated hand hygiene should have been performed on entry, during contamination, and on exit.
An infection control deficiency was cited after an LPN disinfected a glucometer for only a few seconds instead of keeping it wet for the required 2-minute contact time, despite confirmation from the Infection Control Nurse and DON that the device must remain wet between residents. In a separate observation, a resident’s O2 tubing was found lying on the floor under a fall mat; the resident had COPD, cerebral palsy, and severe cognitive impairment, and the DON stated the tubing should not have been on the floor.
A resident with a Stage IV sacral pressure injury and EBP order was observed during incontinent care and wound care with multiple infection control failures. A CNA changed gloves without hand hygiene and did not wear a gown during EBP care, and an LPN continued wound cleansing with gloves contaminated by stool without changing gloves or performing hand hygiene. The DON and IP confirmed the staff actions did not follow facility infection prevention practices.
Infection control practices were not maintained when an RN administered nebulizer treatment to a resident using a mouthpiece that was not stored in a protective bag and was not cleaned before use. In a separate incident, a CNA placed soiled peri-care items on the floor in another resident’s room instead of properly discarding them; the IP and DON confirmed the practice was unsanitary and an infection control concern.
Failure to Use EBP During IV Medication Administration: An RN administered IV ceftriaxone to a resident without wearing a gown as required for EBP. The RN stated she did not know EBP PPE was needed for IV drug administration and said the facility used EBP for catheter and PEG tube care but not for IV site care unless it was a central line. The DON and infection preventionist stated EBP is intended to prevent spread of MDROs and protect residents with indwelling devices such as IVs.
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