Failure to Maintain Clean Technique During Wound Care: An RN performed wound care for a resident with PVD and cellulitis without setting up a clean field, placing wound supplies on the resident’s bed, dropping a dirty glove onto clean supplies, and failing to cleanse hands between glove changes. The DON stated the nurse should have used a clean field, discarded the dirty glove, and cleansed hands between glove changes.
Infection control practices were not maintained for two residents. For a resident on contact precautions with MRSA and wound care needs, an RN placed used vital signs equipment and wound care items on the med cart and later brought the same equipment into another resident’s room without disinfection. For another resident with DM2 receiving sliding-scale NovoLog, the RN failed to remove gloves and perform hand hygiene after blood glucose testing and insulin administration, while touching keys, the med cart, and disinfectant wipes before removing gloves.
Failure to follow EBP occurred when staff did not perform hand hygiene or wear a gown and gloves while assisting a resident with a wound during a transfer. The resident had dementia and a stage 4 pressure ulcer to the ankle, and the EBP sign at the door directed staff to clean hands on entry and exit and use gown and gloves for high-contact care such as transfers. The NA acknowledged not following these precautions, and the LPN, IP, and DON stated that gown, gloves, and hand hygiene were expected.
Improper Disinfection of Blood Glucose Meter: A RN used a resident’s blood glucose meter and then cleaned it with an alcohol prep pad instead of an approved disinfectant before returning it to the med cart. The RN said she had been told to use the alcohol pad and claimed the meter was dedicated to one resident, but she could not provide evidence of dedicated use. The DON stated she expected use of germicidal wipes and also could not verify that the meter was solely assigned to that resident.
Surveyors found that the facility failed to implement Enhanced Barrier Precautions (EBP) in accordance with CDC guidance and facility policy for two residents who had central venous catheters (CVCs) for in-house dialysis. Both residents had physician orders for regular monitoring of their right chest CVC access sites and dressings, but there were no EBP orders in their records. In one case, EBP signage and PPE were posted at the room entrance, but a regional clinical leader stopped the use of PPE and stated the resident did not require EBP, explaining the setup was for an anticipated new admission. In an interview, the Regional Director of Clinical Services acknowledged that the facility does not follow EBP for residents with CVCs for dialysis, despite CDC recommendations that residents with indwelling medical devices, including central lines, be placed on EBP.
Failure to maintain sanitary technique during resident treatments. An RN applied topical cream to multiple body sites without changing gloves or performing hand hygiene between areas, moving from a dirtier area to a cleaner area. The same RN also treated a resident’s wound and skin tear while wearing double gloves, removed only the outer pair, and continued the treatment without removing all gloves, performing hand hygiene, or donning clean gloves before applying the dressing; the DON stated staff would be expected to change gloves and perform hand hygiene between treatments.
Surveyors found that biohazardous waste and sharps were stored in unlocked, unsecured rooms throughout the facility, including a memory care unit, despite a policy requiring sharps to be kept in locked, designated containers and areas. A room off the back entrance contained overflowing boxes and bags of infectious and biohazard medical waste with the door left partially open, and facility leadership acknowledged the room was unlocked and filled with biohazardous waste. On multiple units, surveyors observed overflowing sharps containers, an open sharps container with exposed needles, sharps containers placed on the floor, and IV lines with visible blood hanging from sharps containers, while residents were ambulating nearby. Facility representatives and the contracted waste vendor reported that biohazard waste removal services had been on hold for months due to non-payment, and records showed no licensed biohazard waste removal since that time.
During a norovirus outbreak, a resident with dementia and GI symptoms was placed on contact precautions with posted signage and a physician’s order requiring gown, gloves, and hand hygiene on room entry and exit. A nursing assistant entered and exited the resident’s room without wearing PPE, did not perform hand hygiene, then accessed a clean linen room and returned to the resident’s room still without PPE. The staff member later acknowledged knowing the resident was on contact precautions for norovirus and that she failed to follow the posted instructions, while facility leadership stated they expected staff to adhere to the contact precaution requirements.
A facility failed to manage a respiratory illness cluster and did not consistently use empiric or transmission-based precautions for multiple residents with cough, congestion, shortness of breath, and other respiratory symptoms. The IP and DNS could not show that residents were tested for RSV or influenza or placed on precautions as symptoms emerged. The facility also failed to clean a resident’s BiPap equipment as required, and staff were observed entering precaution rooms without the required PPE, wearing PPE in the hallway, and failing to perform hand hygiene.
Failure to follow EBP precautions occurred when a CNA dressed, bathed, and transferred residents without wearing a gown as required by posted signage, and a laundry aide moved between rooms of residents on EBP without sanitizing her hands. The DON acknowledged that the residents were on EBP and that staff should have worn a gown and gloves for dressing, bathing, and transferring, while the aide initially claimed to have used room sanitizers even though the dispensers were empty.
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