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 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 Staff interviews revealed outdated or incomplete training on transmission-based precautions, misunderstanding of eye protection and Enhanced Barrier Precautions, and the facility could not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.
Enhanced barrier precautions were not followed during wound care for a resident with a sacral pressure ulcer and bilateral heel pressure ulcers: one nurse used the same soiled glove after repositioning a chair and continued debriding the heel wound, and another staff member provided wound dressing care without wearing an isolation gown. The facility also failed to complete required weekly documentation for its water management program, with multiple weeks showing no action recorded and 22 of 52 weekly monitoring activities lacking documentation.
EBP signage was missing for two residents, and staff did not consistently follow EBP during catheter care for residents with a suprapubic catheter and a Foley catheter. Staff were observed handling catheter care without the proper PPE, performing incomplete perineal care, and emptying a full catheter bag with poor hand hygiene practices. Hand sanitizer in four resident rooms was not working or was empty, and one resident reported frequent UTIs and prior sepsis related to catheter care issues.
Staff failed to use PPE correctly when caring for residents on enhanced droplet or droplet precautions, including COVID-19 positive residents and a resident with a respiratory virus. Observations showed staff entering rooms without gowns, eye protection, or proper hand hygiene after care, and one staff member handled a resident’s tray and other items after removing PPE without washing hands. The facility also had an incomplete infection surveillance log that lacked key tracking details such as room numbers, onset dates, infection sites, and totals for active infections.
Hand Hygiene and Clean Barrier Not Followed During Wound Care An LPN performing wound care for a resident’s coccyx placed dressing supplies on the resident’s wheelchair without a clean barrier and changed gloves multiple times without washing hands or using hand sanitizer between glove changes. The LPN stated she had not performed hand hygiene between glove changes, and facility guidance stated hand hygiene was required before donning and after removing gloves.
Failure to Complete Pre-Employment TB Screening: The facility did not ensure TB screening was completed for new hires as required by its infection prevention and control program, facility policy, and CDC guidance. Staff stated there was no system to track employee TB screening, and record review showed many employees had no documented TB test, while others were tested only after surveyor request or at unverified outside locations.
Infection control practices were not followed during resident care, linen handling, and storage. A resident on antibiotics for a UTI reported being left wet and said a CNA wiped from back to front; during observed peri-care, staff did not use the required PPE for EBP and did not clean the front peri-area. For another resident, staff changed gloves but did not perform hand hygiene between dirty and clean toileting tasks. Dirty linen was carried unbagged in the hall, clean pillows were stored in the dirty linen room, and multiple clean supplies and room surfaces were found improperly stored or damaged.
The facility failed to review its infection prevention and control program annually and did not follow EBP standards for two residents with suprapubic indwelling catheters. Staff observed caring for the residents without EBP signage or the required PPE, and staff stated they used standard precautions or were unaware of any additional PPE needed. The residents’ orders and care plans addressed catheter care, but did not address EBP.
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