Infection control standards were not followed during care for two residents on EBP with indwelling catheters. During one resident’s bed bath, a CNA used the same washcloth for peri-area, catheter tubing, legs, buttocks, and back care, did not cleanse the genital area last, and did not sanitize the bedside table after removing the basin. During another resident’s lift transfer, staff did not use the required gown and glove PPE.
Staff failed to follow infection control practices during resident care, medication pass, and laundry handling. A CNA and a nurse performed high-contact care for residents with soiled gloves, did not consistently perform hand hygiene after glove removal, and did not use gown and glove PPE as required for EBP. A medication aide administered an inhaler without hand hygiene, and the laundry room had mixed clean and soiled items with inadequate PPE availability.
Failure to follow infection control standards occurred when staff did not fully use EBP during resident care and did not disinfect shared equipment after use. A CNA cared for a resident requiring EBP without wearing a gown during toileting and perineal care, and during care for another resident, a CNA handled a radio with gloved hands and returned it to a pocket without disinfecting it after leaving the room.
Infection control standards were not followed during catheter care and resident assistance for two residents. CNAs drained urine from catheter bags and closed the spouts without sanitizing them, and during perineal care for one resident, a CNA removed soiled gloves, put on clean gloves without hand hygiene, and continued with both dirty and clean tasks using the same gloves before finally removing PPE and cleaning hands.
Staff failed to follow infection control practices during resident care, including EBP use, hand hygiene, glove changes, catheter bag handling, and equipment disinfection. A nurse did not wear a gown for high-contact device care for a resident on EBP, a Foley catheter bag was allowed to drag along the floor, and CNAs handled soiled and clean tasks without proper hand hygiene or disinfection of contaminated items and surfaces.
Staff failed to follow infection prevention and control policies when handling reusable equipment and soiled linens for two residents, including one on enhanced barrier precautions (EBP). A CNA removed a full body mechanical lift from a resident’s room without disinfecting it, despite facility expectations for cleaning after each use. In a separate incident, CNAs entered the room of a resident on EBP wearing only gloves initially, and one CNA placed soiled linens on the floor instead of directly into a bag, even after donning a gown. An RN later confirmed that staff were expected to disinfect lifts after every use, avoid placing soiled linen on the floor, and wear gowns upon entering EBP rooms.
Staff failed to follow infection control practices during multiple resident care tasks, including perineal care, ostomy care, dressing changes, insulin administration, and blood glucose monitoring. CNAs and an RN were observed removing soiled gloves and continuing care without hand hygiene, handling clean supplies without establishing a clean field, administering insulin without gloves, and disposing of contaminated items with a bare hand. These lapses occurred during care for several residents and during EBP care.
Staff failed to follow infection control practices during resident care and medication tasks. A CNA did not use gown and gloves as required during toileting and catheter-related care, another resident with MRSA and multiple wounds did not have EBP in place during brief care and transfer, and a CNA touched equipment and other items without proper hand hygiene or glove changes during EBP care. A nurse also moved from dirty to clean wound care without changing gloves or performing hand hygiene, gave oral meds and eye drops without changing gloves, and prepared insulin pens without disinfecting the rubber stoppers.
Hand hygiene and glove use were not followed during observed resident care. A CNA cared for a resident on Enhanced Barrier Precautions for MRSA, removed PPE, and then went to another resident without sanitizing hands. In another observation, a CNA changed gloves multiple times during toileting care for a resident but did not perform hand hygiene between glove changes. An administrative nurse confirmed staff should sanitize hands between residents and after removing soiled gloves and applying clean gloves.
Surveyors found that staff failed to follow the facility’s hand hygiene policy and proper glove use during a wound dressing change and multiple episodes of personal and toileting care. A nurse performing a dressing change did not remove soiled gloves after disinfecting a bedside table and did not perform hand hygiene between glove changes while cleansing and redressing a wound. In separate observations, CNAs providing perineal care, toileting assistance, and hygiene for two residents repeatedly removed soiled gloves and donned clean gloves without performing hand hygiene, and continued dressing, repositioning, and transferring the residents without required hand cleansing between glove changes.
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