A resident with ESBL and severe cognitive impairment was placed on contact isolation, but the chart contained no physician's order for transmission-based precautions. Staff observed that the room had only a personal trash can, with no separate receptacle for isolation PPE, and the DON confirmed PPE had been disposed of in the resident's personal trash can.
Failure to use required PPE for droplet precautions: A resident with pneumonia due to mycoplasma pneumoniae, COPD, and oxygen dependence was on droplet isolation, but an RN and a CNA entered the room wearing only a mask and gloves. The door had an enhanced barrier precaution sign and supplies, but no goggles or face shield were available at the room, and staff stated they believed only a mask and gloves were required.
Infection Control: Improper Glove Use An RN was observed exiting a resident's room carrying a closed plastic bag with soiled gloves still on, then entering the code to the soiled utility room while wearing the same gloves. The RN confirmed the glove use in the hallway and into the soiled utility room and stated the bag contained a soiled brief. The facility policy states gloves are to be discarded after each use and hand hygiene performed immediately after removal.
PPE was not available for laundry staff in the laundry room while sorting soiled resident clothing and bed linens. A Laundry Aide stated she only had disposable gloves and did not have access to gowns or industrial strength gauntlet gloves, and the IP verified there was no PPE in the soiled laundry shoot area. The facility’s policy stated the laundry area would provide PPE, and the DON stated laundry staff were expected to have access to PPE to prevent cross contamination.
Infection Control Lapse During Wound Care: A resident with multiple pressure ulcers, paraplegia, immunodeficiency, and a history of sepsis and bacteremia had wound care observed by the WCN. The WCN and helper donned gowns in the hallway, then the WCN used already opened gauze, touched the wound, discarded gauze in a bedside trash bag, and continued wound cleaning without hand hygiene or changing gloves before handling additional gauze. The WCN also moved the bedside and opened the trash bag multiple times while an AC blew on the supply area during dressing changes.
Excessive Lint on Dryer Screens: Surveyors found excessive lint on the lint screens for 2 commercial dryers in the main laundry room. The laundry policy required equipment to be maintained per manufacturer instructions, and the dryer instructions said the lint filter should be cleaned to maintain proper airflow and avoid overheating. The HD and LA stated they were unaware the lint screens existed, and the HD reported he had been cleaning the walls, floors, and behind the dryers but had never cleaned the lint screens.
An LPN and a CNA failed to follow EBP for a resident with a wound and recent below-the-knee amputation. The resident’s room had an EBP sign requiring gloves and a gown for high-contact care, including wound care and changing linens, but the LPN performed wound care without a gown and the CNA changed linens without a gown or gloves. The LPN said she forgot the gown, and the DON and CNA gave conflicting statements about PPE use during linen changes.
Improper PPE availability and incorrect TBP signage were observed for two residents on contact/droplet precautions. One resident had RSV and conflicting room signage, while a housekeeper entered the room wearing personal work gloves and stated extra-large disposable gloves were not available in the drawer. For the other resident, EBP signage was posted instead of contact/droplet signage, and staff entered without PPE until the MDSC intervened; an LPN also stated eye protection was not worn when entering the first resident's room.
Failure to Follow EBP During Resident Care: An LPN did not wear a gown while providing wound care to a resident with chronic leg wounds and EBP orders. In a separate observation, an LPN wore gloves while administering eye drops to a resident with wounds and lymphedema, then exited the room without removing the gloves or performing hand hygiene. Facility policy required gown and glove use for high-contact care activities, including wound care, and staff interviews confirmed the expected EBP practices.
A resident with septicemia and bacteremia was on EBP and had meds administered through a PICC line while sitting in a common area. Two LPNs gave Heparin Lock Flush, NS, and ceftriaxone without PPE and both touched the resident during the procedure. One LPN said he had not given IV meds through a PICC before, and the DON said the assisting agency LPN had no known training in IV med administration.
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