Staff failed to follow infection control precautions during resident care, including improper glove changes, missed hand hygiene, and failure to use required PPE and EBP. During toileting, transfers, and other hands-on care, CNAs removed and reapplied gloves without hand hygiene, touched their own face while gloved, and handled equipment and room items without cleaning their hands. Other residents with C. difficile, chronic wounds, or indwelling devices did not have required EBP or TBP measures in place, and staff entered rooms without the required gown, gloves, mask, or soap-and-water handwashing.
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.
Hand hygiene and glove use were not followed during resident care for multiple residents. A nurse changed gloves and moved from contaminated to clean tasks without hand hygiene and did not assist a resident with hand hygiene after wound care. CNAs also failed to perform hand hygiene after a lift transfer and after perineal care before moving to clean tasks, and staff passed drinking glasses by touching the rims with bare hands.
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.
Infection control practices were not followed during care for multiple residents with contact precautions or EBP needs. Staff repeatedly failed to perform hand hygiene after removing gloves and before touching clean items or changing tasks, and some staff did not wear required gowns and gloves during resident care. One resident had MRSA with contact precautions and a feeding tube, another had a pressure ulcer with EBP, and staff were observed providing urinary catheter, toileting, perineal, and feeding tube care with repeated breaks in PPE and hand hygiene.
Infection control standards were not followed for a resident with a PEG tube, PICC line, and MDRO precautions. Maintenance staff entered and exited the room multiple times while working on a call light and did not sanitize their hands when leaving. Later, an RN assisted with brief care and then accessed the PICC line without removing soiled gloves, performing hand hygiene, donning clean gloves, or sanitizing the PICC port before attaching a syringe.
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.
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