The facility failed to maintain infection control for multiple residents. A resident with a worsening sacral wound and antibiotic orders was not tracked in the antibiotic stewardship or infection control programs and did not have EBP signage posted. Two other residents with sepsis, a stage 4 PU, ESBL, and E. coli also lacked EBP signs, and staff observed providing high-contact care without PPE.
Failure to maintain infection prevention and control measures by not posting EBP signage or ensuring PPE was readily available outside the rooms of two residents with indwelling catheters. The DON stated both residents should have been on EBP because of their catheter use, but they were not.
Infection Control Failures During Wound Care: An LPN failed to wear the required gown throughout wound care for a resident on barrier precautions, blew on hands after applying alcohol-based hand sanitizer, and later rubbed hands on pants after washing and drying them before continuing the dressing change. The LPN confirmed the actions were improper, and the ADON stated that a gown should be worn throughout wound care and that hand hygiene should be performed without blowing on hands or wiping them on pants.
A resident with peripheral vascular disease, muscle weakness, CHF, and an active wound infection was on Enhanced Barrier Precautions (EBP) with posted signage requiring PPE use for direct care. Facility policy required targeted gown and glove use to prevent transmission of multidrug-resistant organisms. Despite this, a CNA was observed providing direct care to the resident without any PPE and later acknowledged that PPE should have been worn, while the DON stated the expectation that all staff follow EBP guidelines.
A resident with sepsis, morbid obesity, an abdominal wound vac, an unstageable sacral pressure ulcer, and an actual infection with a surgical wound did not have required Enhanced Barrier Precautions (EBP) signage posted in the room, and PPE was not readily accessible. During observed wound care, an LPN performed treatment without donning a gown. In interviews, the LPN reported believing gowns were only required for residents on transmission-based precautions, and the IP stated that EBP was only needed for residents with infected wounds, demonstrating a failure to implement EBP and appropriate PPE use during high-contact wound care activities.
Surveyors found that a lunch tray return cart containing uncovered, soiled food trays and dishes was left unattended in a main hallway outside an activity room. The housekeeping/laundry manager acknowledged seeing the unattended cart, and the Dietary Manager confirmed that such carts are supposed to remain only in designated areas, such as near the nurse’s station or in the kitchen, and should be returned to the kitchen for cleaning as soon as all trays are collected. This failure was cited as likely to expose all residents to potential pathogens associated with food waste.
Surveyors identified failures in infection prevention and control when a CNA exited a room wearing a gown and gloves instead of doffing PPE before leaving, contrary to the IPC’s stated expectations. In a separate case, a resident admitted with C. diff and a Foley catheter had no EBP signage or PPE available near the room, despite an LVN acknowledging that EBP should have been in place for this resident.
A resident with a G-tube, indwelling catheter, unhealed pressure ulcers, and ongoing wound care orders required Enhanced Barrier Precautions (EBP), but staff failed to post EBP signage at the room entrance during multiple observations. The resident had active orders for enteral feeding, catheter management, and daily wound care. The ADM and DON both acknowledged that the resident met criteria for EBP and that signage is used to inform staff of required precautions, yet no such signage was present, demonstrating a failure to implement the infection prevention and control program.
Surveyors found that a resident with a Foley catheter, care planned for this device, did not have required enhanced barrier precaution signage or PPE (gowns and gloves) available outside the room. During observation, no sign or PPE was present, and in interview the UM confirmed their absence and acknowledged that both were expected for this resident due to the Foley catheter. This deficiency was identified for one of three residents reviewed for Foley catheter-related infection control practices.
The facility failed to maintain infection control for two residents. A resident with an indwelling urinary catheter was observed with the drainage bag and tubing hanging from a wheelchair and touching the floor, despite staff expectations that it remain below the bladder and off the floor. Another resident with COPD and continuous oxygen was observed with the oxygen humidification container on the floor, and it remained there on repeat observation; an LPN and the DON both stated this was not appropriate because it is an infection control issue.
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