An LPN failed to follow infection control practices during wound care for a resident with diabetes, chronic venous ulcers, and PVD by placing supplies on the resident’s bed, putting soiled items on the recliner and bed, not using required PPE/EBP signage, and not disinfecting supplies before returning them to the cart. Staff also failed to perform proper peri-care and hand hygiene for two residents who were incontinent and dependent for toileting care, including donning and changing gloves without HH, using soiled gloves during wiping, not cleansing the buttocks area, and moving from one resident’s care to another without HH.
Infection control standards were not followed during wound care and resident care for two residents. An LPN changed gloves during wound care without performing hand hygiene, and an RN and DON were observed doing a bed change without gowns for a resident on EBP. During wound care, the RN touched the resident’s foot with clean gloves, used scissors from a pocket without cleaning them, and later handled resident items and clean supplies without hand hygiene, with the RN and DON confirming cross contamination occurred.
The facility failed to follow infection control practices during resident care, including hand hygiene, glove changes, perineal care, and EBP use. Staff were observed providing care to residents with a feeding tube, wound and colostomy needs, and toileting assistance without proper hand hygiene or correct PPE, and one resident’s nebulizer equipment and a urine-filled urinal were left improperly stored near feeding supplies. A maintenance director also entered a room under neutropenic precautions without a face mask or hand hygiene.
The facility failed to maintain an effective infection prevention and control program because infection tracking and trending documentation was incomplete and infection counts in QA notes did not match the Infection Surveillance Report. The IP confirmed the report lacked key details such as room numbers, signs and symptoms, labs, and antibiotic days, and the wound nurse’s documented audits were education rather than actual observations. The facility also failed to use proper hand hygiene and glove technique during incontinent care for a resident with severe cognitive impairment, bowel and bladder incontinence, and a recent UTI; NAs were observed using soiled gloves, reusing wipes, handling soiled linens, and leaving the room without hand hygiene.
A resident receiving enteral feeding had a Kangaroo ePump running with the display showing “Set Use > 24 hrs” on repeated observations. The facility policy addressed infection control precautions for feeding tubes, and the pump instructions recommended replacing pump sets after 24 hours of use. An RN confirmed the pump set should be changed when the tube feeding bag was replaced, and the ADON confirmed there was potential for cross contamination if the pump set was not changed every 24 hours.
Staff failed to follow infection prevention and control practices during blood glucose monitoring and while providing care under Enhanced Barrier Precautions. An LPN performed serial blood glucose checks for two residents with T2DM without changing gloves between residents, without performing hand hygiene when changing gloves, and without cleaning the glucometer between uses, while also handling test strips directly from the cannister with contaminated gloves. In a separate incident, a resident with ESRD on dialysis and a documented care plan for EBP, including gown use for high-contact care such as brief changes, received incontinence care from a NA who did not wear a gown, despite posted EBP signage and later acknowledgment that a gown should have been used.
Surveyors found that staff did not consistently follow EBP, hand hygiene, or glucometer disinfection policies. A resident with MRSA/MDRO history and MASD had an EBP sign and care plan requiring gown and gloves for high-contact care, yet staff performed peri care and transfers wearing only gloves, and several aides and the IP showed inconsistent understanding of which residents were on EBP and what constituted high-contact care. Multiple staff, including MAs, were observed donning and changing gloves for cares such as insulin administration and peri care without performing required hand hygiene, and one aide noted the absence of hand sanitizer in resident rooms. An LPN used the same glucometer on two residents without cleaning or disinfecting it between uses, contrary to facility policy, and later stored the device still un-sanitized in the medication cart.
Failure to use required PPE during wound care: A resident on EBP for multiple wounds had wound care performed while a hospice RN was in the room without a gown. The RN touched the resident’s wounds and lifted the resident’s lower extremity several times while an LPN applied dressings, despite posted EBP guidance requiring gloves and a gown for high-contact care such as wound care.
Surveyors found that staff failed to follow infection control practices during wound care for two residents. For one resident with diabetes, venous insufficiency, edema, and cellulitis, an RN turned off the faucet with bare hands and then used a contaminated gloved hand to manipulate a xeroform dressing that was placed directly into an open wound. For another resident with quadriplegia, multiple wounds, and an ESBL infection, an LPN performed extensive wound care to the hand using gloves and hand hygiene but did not wear a gown as required under EBP orders for high-contact activities.
Staff failed to consistently follow infection control practices when caring for residents in Red Zone and Light Red Zone rooms. Observations showed NAs and an Hskp moving between infectious and non-infectious rooms while wearing the same PPE, not changing masks or disinfecting eyewear, not performing HH, and handling dishes, supplies, and handrails in the hallway. The DON and IP were also observed in the area while these practices occurred, and the Hskp confirmed rooms on transmission-based precautions were cleaned interspersed with rooms that were not on precautions.
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