EBP was not identified or initiated for residents with wounds, a skin lesion, or an indwelling Foley catheter, as signage was missing and PPE was not readily accessible at the point of care. In addition, a staff member distributing clean linen entered multiple residents’ rooms and handled clean clothing without performing hand hygiene before entering, after exiting, or before touching clean linen.
Improper hand hygiene and glove use during medication pass were observed with two residents. An RN/LPN entered one resident's room without hand hygiene, handled the Rover and medication cards, prepared oral meds, and gave a B-12 injection after donning gloves without first cleaning hands. In another resident's room, a staff member prepared and administered meds, removed and applied patches, and changed gloves without hand hygiene before or after glove use, including after touching dirty equipment and before applying patches to clean skin areas.
Infection control practices were not followed during meal service and resident care. A staff member served a resident from a cup with a crusted substance on it, and another staff member touched her hair and pockets while setting up and serving trays without hand hygiene. During care for a resident with wounds and fecal incontinence, staff mixed clean and soiled linens, left a Hoyer lift uncleaned, and moved from one wound to another without removing gloves or performing hand hygiene between wounds.
A resident with a chronic Foley catheter was observed with the drainage bag on the floor while staff administered meds, despite facility policy requiring the bag and tubing to be kept off the floor. Another resident who was dependent on continuous O2 was observed with nasal cannula tubing that was not dated, and the MAR/TAR showed no documentation of tubing changes. Staff gave inconsistent statements about how often O2 tubing should be changed and how it should be documented.
The facility failed to keep infection control policies and the reportable communicable disease list current. Staff reported that the infection control program and policies had not been reviewed recently, and record review showed outdated policies for influenza immunization, pneumococcal immunization, and ASP, along with an infection control prevention policy last updated well before the survey. The facility also used an old communicable disease reporting list dated years earlier instead of the current county health department list.
Staff failed to follow hand hygiene practices while caring for a resident with weeping, hot lower legs who had been started on antibiotics for cellulitis. One staff member removed TED hose from the resident’s weeping left leg and then immediately assessed the right leg without changing gloves or performing hand hygiene. Another staff member, after applying TED hose to the weeping leg while gloved, continued to handle the resident’s food, pillow, and personal items and answered a cell phone by placing her gloved hand into her pocket, all without changing gloves or performing hand hygiene, contrary to the facility’s hand hygiene policy.
Failure to implement infection prevention and control program: Two residents with wounds were not placed on EBP, and staff did not know when to use gowns and gloves for high-contact care or wound care. One resident had pressure ulcers on the heel and coccyx, and another had bilateral foot dressings with heel protectors. The IP staff member stated infections and pathogens were not being tracked or mapped, a recent Norovirus outbreak was not entered into the infection control logbook, and the logbook contained only nonspecific infection entries without surveillance or analysis.
Failure to perform hand hygiene during meal tray service: A new staff member handled meal trays, a resident's wheelchair, and silverware without cleaning his hands between contacts. He placed an uncovered tray on a dining room table, delivered another tray to one resident, and then pushed another resident's wheelchair to the table before handling the resident's silverware. Facility hand hygiene policy required hand hygiene between resident contacts and after handling contaminated objects.
Failure to follow infection control practices during a med pass affected two residents. An LPN prepared and administered meds while wearing gloves without hand hygiene, touched multiple potentially contaminated surfaces, changed gloves without hand hygiene, and entered residents' rooms after touching door handles without performing hand hygiene before medication administration.
Surveyors found that a resident on Enhanced Droplet Precautions for COVID-19 did not receive care consistent with posted PPE and hand hygiene requirements. Staff repeatedly entered and exited the resident’s room wearing only a face mask, without gowns, gloves, or eye protection, and did not perform hand hygiene between resident contacts. The PPE cart lacked gowns, no used gowns were found in the room trash, and the resident reported that staff did not always wear full isolation gear. Staff interviews revealed outdated or incomplete training on transmission-based precautions, misunderstanding of eye protection and Enhanced Barrier Precautions, and the facility could not provide documentation of current staff education despite having policies and CDC guidance requiring full PPE for COVID-19.
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