An LPN and RN failed to perform hand hygiene between multiple glove changes while providing wound care to a resident with open thigh wounds and a pressure ulcer. The staff removed and replaced gloves repeatedly during dressing removal, wound cleansing, application of wound products, and brief care without HH in between, and the LPN stated HH was only needed before and after wound care.
An RN failed to perform hand hygiene or change gloves during gastric tube site dressing care for a resident with dysphagia and prior stroke diagnoses. A staff member also stored a cell phone and lip balm in a medication cart drawer on top of resident tissues, and a housekeeper handled a soiled mop pad without gloves and then touched a housekeeping cart, binder, and nutrition room door handle without hand hygiene. The DON, IP, and staff confirmed these actions did not follow facility infection control and storage practices.
Empty Restroom Soap Dispenser: A restroom designated for staff and visitor use had a soap dispenser with a clear cartridge completely empty and no alternative hand hygiene products available. An RN confirmed the dispenser was empty and said Housekeeping was responsible for replacing soap cartridges before they ran out. The IP stated Housekeeping routinely checked dispensers and acknowledged soap should have been available at all times as part of standard precautions.
Infection surveillance data was not used to identify the cause of multiple facility-acquired infections across several months, including COVID-19, UTIs, PNA, yeast infections, cellulitis, C. diff, skin rashes, and wound infections. The Infection Preventionist stated the facility had not provided staff education specific to the surveillance data and had not analyzed the data to determine why the infections were occurring, despite the facility policy requiring surveillance for prevention, identification, investigation, and control of infections.
Isolation Precautions were not implemented correctly for a resident with rhinovirus/enterovirus, as EBP signage was initially posted instead of Droplet Precautions signage and staff interviews showed confusion about the required PPE and timing of isolation. The DON later stated the resident should have been placed on isolation immediately, and the facility’s infection control materials were also incomplete because the IPCP did not include COVID staff immunizations, work restrictions, or resident care guidance, and staff could not locate a COVID policy.
A resident with an implanted chest port and IV antibiotics had contact precaution signage posted, but an RN drew blood from the port without a gown and repeatedly accessed the line while moving in and out of the room. Staff interviews showed confusion about contact precautions vs EBP, and the DON stated the resident should have been on EBP and that a gown should have been worn for IV line care.
A resident with metabolic encephalopathy, metabolic acidosis, rhabdomyolysis, and neuropathy had a peripheral IV catheter in the left forearm without documented physician orders for insertion, monitoring, or discontinuation. The IV dressing was unlabeled, and an LPN confirmed there were no orders for the catheter’s care or removal; the DON later acknowledged the catheter should have been discontinued when no longer in use.
EBP and PPE were not implemented for a resident with a G-tube. The resident had diagnoses including CVA sequelae, syncope and collapse, UTI, and hypothyroidism, and staff observed no EBP sign or PPE such as gowns at the room door. An LPN, RN Manager, RNs, and the Central Supply Clerk all confirmed that gown and glove use was required for high-contact G-tube care and that PPE should be available at the room entrance.
Unsanitary Kitchen Floor Drain: A kitchen floor drain was observed with a buildup of debris and grime, and the Kitchen Mgr confirmed it was dirty and could spread contamination. The Mgr stated floor cleaning was the responsibility of Maintenance, and the Maint Mgr later confirmed the drain had not been recently cleaned and was not sanitary. The facility policy required strict sanitary conditions in Dietary and Nutrition to prevent food contamination and growth of disease-producing organisms.
Failure to Use Appropriate Isolation Precautions for an Immunocompromised Resident: A resident with cancer diagnoses and chemotherapy-related immune suppression did not have the correct isolation precautions in place. An EBP sign was posted outside the room, but it did not direct staff or visitors to wear masks, and CNAs entered without masks. The CNO confirmed the resident was immunocompromised and that reverse isolation precautions, including mask use by staff, visitors, and the resident when leaving the room, should have been followed.
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