Foley catheter drainage bag left on floor. A resident with a Foley catheter, bladder dysfunction, and prior CVA was observed lying in bed with the catheter drainage bag resting on the floor. RN, the UM, and the DON each stated the bag should not be on the floor because it could increase contamination and infection risk.
Infection control precautions were not consistently followed for residents on contact precautions and EBP. A CNA entered a resident’s room without PPE and later handled food and a drink cup in the dining area without hand hygiene, a RN entered another resident’s room without PPE while taking vital signs, and a third resident with an open wound did not have EBP signage or PPE posted outside the room. The DON confirmed the expected PPE use for these situations.
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.
A resident with a Foley catheter was ordered to be on EBP, but surveyors observed that gowns were not visible in the room and the resident stated staff did not wear gowns when transferring him or showering him. Staff interviews showed confusion about when gowns and gloves were required, and an LPN later found gowns stored in the resident’s dresser drawer rather than readily available at the room entrance.
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.
The facility failed to maintain EBP for residents with wounds and indwelling devices. A resident with a PEG tube, a resident with an open foot wound and IV antibiotics, a resident with a Foley catheter and toe wound, and a resident with a PICC line all had issues with EBP signs, PPE placement, or gown use during high-contact care. Staff and the IP confirmed that gowns and gloves were expected for close contact tasks such as transfers, showering, wound care, and device care, but residents reported staff often used gloves and masks without gowns.
A resident with a foley catheter due to neurogenic bladder was observed in a wheelchair with the urinary catheter bag dragging on the floor while being pushed to activities. An LPN stated catheter bags should be secured below the bladder and not touch the ground, and the DON stated the bag should not be dragging or laying on the floor.
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.
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