Infection prevention practices were not followed during medication administration for a resident. An LPN placed medications and two medication boxes on the resident’s bedside table without disinfecting the surface or using a barrier, then returned the boxes to the med cart where they contacted other residents’ medications. The DON and IP confirmed the table should have been disinfected and a barrier could have been used.
A facility failed to implement Contact Precautions for two residents by not placing designated containers in their rooms for contaminated PPE, linens, and other materials. Staff were observed and reported discarding gowns, gloves, and other contaminated items in regular trash and routine laundry instead of using the required disposal containers. One resident was on Contact Precautions for ESBL UTI, and another was on Contact Precautions for an MRSA wound.
Infection control was not maintained when an LPN disinfected a multi-use glucometer for only a few seconds between resident blood glucose checks instead of the required two-minute wet contact time, and placed the device directly on the med cart and bedside table without a barrier. Staff also left blood-contaminated linens on the floor in a resident room after a fall with a head laceration, rather than containing them in a biohazard bag and sending them to the laundry biohazard barrel.
Improper Storage of Nebulizer Mask: A resident receiving ordered nebulizer treatments had the nebulizer mask observed lying on the floor after staff exited the room. The IP confirmed the mask was not in a protective bag, and an RN stated the mask should be rinsed, dried, and stored in a clean bag after each treatment. The resident had chronic respiratory failure with hypoxia, COPD with emphysema, and influenza, and was cognitively intact.
Failure to Perform Hand Hygiene During Wound Care: An RN provided wound care to a resident with a right foot wound and changed gloves multiple times without performing hand hygiene between glove changes. The RN confirmed the omission and said she was unsure whether she could leave the room to get hand sanitizer after donning a gown; the DON stated staff were expected to follow CDC hand hygiene guidance.
A CNA assisted a resident with removing clothing and then used the same gloves to provide catheter care without performing hand hygiene first. The Infection Control Nurse and DON confirmed hand hygiene should have been done before catheter care, and the resident had diagnoses including urinary retention and infection/inflammatory reaction related to an indwelling urethral catheter, with a BIMS score of 12.
Failure to follow infection control practices was observed with two residents. An RN changed gloves during wound care for a resident with severe cognitive impairment but did not perform hand hygiene between glove changes or before moving to a second wound, despite facility policy requiring hand hygiene after glove removal. In a separate observation, an LPN administered G-tube meds to a resident with EBP indicated but did not wear a gown, and her scrubs contacted the resident’s linens while handling the tube area; the DON and IP stated gowns were required under EBP.
Failure to use EBP during wound care and incontinent care: an RN and a CNA provided direct care to a resident with a Stage 3 sacral pressure ulcer without wearing the required gown, despite the resident being identified for EBP. The resident had unspecified dementia, moderate cognitive deficits, and an ordered daily dressing treatment for the sacral wound; staff acknowledged they forgot to don the gown during care.
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.
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