A facility failed to maintain its infection prevention and control program when two residents were placed in the same room even though one resident had MRSA and was on contact precautions. Staff were unsure of the other resident’s MRSA status, the record did not show MRSA for that resident, and the DON later acknowledged the resident should not have been roomed with the MRSA-positive roommate.
Failure to use EBP for residents with wounds and a PICC line. Two residents had draining wounds with orders and care plans indicating EBP, and one resident had a PICC line and wound with EBP ordered. Surveyors observed an RN perform wound care without a gown, another RN change a draining wound dressing without a gown, and an LPN access a PICC line without a gown. Staff stated they were unaware the residents were on EBP because there was no signage, and the IP and DON could not provide evidence that EBP was being used as required.
Infection control practices were not maintained during blood glucose monitoring, insulin administration, and wound care. An LPN exited a Droplet Precautions room wearing contaminated PPE before obtaining insulin, an RN failed to keep a glucometer disinfectant wet for the required dwell time, and staff did not implement EBP for a resident with a chronic, non-pressure wound requiring complex dressing care. The DNS acknowledged staff should follow manufacturer guidance and that EBP had not been initiated for the wound resident.
A resident admitted with type 2 DM, hepatitis C, and a Prevena wound vac had a physician order to keep the wound drainage system in place and monitor for infection. Surveyors observed no EBP signage or appropriate PPE at the doorway on multiple occasions, and the IP later acknowledged the resident was not on EBP and could not explain why.
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 failed when a resident with an indwelling catheter and EBP had the drainage bag disconnected, with urine dripping onto the floor, and an NA reconnected the tubing without cleaning the connection points or wearing a gown. The facility also kept a pneumonia vaccine policy that still referenced PCV13 even though current ACIP guidance no longer recommends it.
Infection Control Precautions Not Followed: Staff did not consistently follow EBP and contact/droplet precautions for multiple residents. An RN flushed a resident’s G-tube without the required gown under EBP, and staff caring for residents on RSV precautions entered rooms without the PPE listed on signage, including missing face shields, gowns, and gloves. One resident’s doorway signage was also inaccurate, and the DON could not provide evidence that the infection control practices were maintained.
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.
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