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.
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 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.
Laundry staff were not aware of the PPE available for sorting dirty laundry. During observation, no face shields or goggles were seen in the sorting area, and a laundry aide stated her apron was at home, the gloves were on the wall, and she used reading glasses instead of eye protection. The DON later stated the expectation was that aprons not be taken home and that face shields be available for eye protection, while the facility policy required laundry staff to handle linens to prevent spread of infection.
PPE Not Available in Laundry Room: Gowns were not available in the laundry room for staff handling soiled linens. A laundry aide confirmed gowns had to be obtained from another area of the facility, and the IP acknowledged the gowns should have been accessible to protect staff and prevent contamination. The facility had multiple current resident infections, including C. diff, wound infections, and cellulitis, and facility policy required staff sorting or washing linen to wear gowns and gloves.
A resident on contact precautions for C. diff was observed in a private room with a family member seated close to the bed, barefoot, and not wearing a gown or gloves. The family member’s dog was also on the bed, and the family member said staff had told them PPE was optional. The IP stated PPE use was not optional for family members, and the facility policy required staff and visitors to wear gloves and a disposable gown when entering the room.
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