Failure to Follow Contact Precautions: A CNA entered a resident’s room without gloves, a gown, or hand hygiene despite contact precautions for ESBL and VRE. The CNA spoke with the resident, touched the resident’s bed sheet, and left without sanitizing her hands. The resident had osteomyelitis, ESBL resistance, VRE, and moderate cognitive impairment, and her care plan and orders required strict single-room isolation with contact precautions.
A CNA entered a resident’s room to deliver a meal tray without donning PPE even though the resident was on contact isolation precautions and signage was posted outside the room. The CNA said PPE was not needed because no care was being provided, while the unit’s LPN manager and the DON confirmed PPE was required; the DON also noted the resident’s tray with reusable dishware was returned to the kitchen on the cart.
A CNA entered a resident’s room under enteric precautions without hand hygiene, gown, or gloves, removed the resident’s lunch tray, and placed it with other dirty trays without washing her hands afterward. The resident had multiple chronic conditions and was on Transmission Based Precautions, while the posted sign and facility policy required gloves, gown, and soap-and-water hand hygiene. Surveyors also found PPE carts stocked with non-PPE items such as cards, a stethoscope, a BP cuff, lotion, briefs, and other personal items.
Foley Catheter Bag Left on Floor: A resident with an indwelling urinary catheter and diagnoses including vascular dementia and urinary retention was observed in bed with the catheter drainage bag resting on the floor on two occasions. The facility's closed urinary drainage procedure required the bag to be attached to the bed frame below the bladder and not touching the floor. A CNA confirmed the bag was on the floor, and the DON and an LPN stated the bag should be hooked to the bedframe off the floor.
Failure to Bag Soiled Linen at Point of Use: A CNA was observed carrying soiled linen from a resident room down the hallway while wearing gloves, rather than bagging it at the point of use as required by facility policy. The CNA stated she worked for hospice and did not agree that transporting unbagged soiled linen past other residents was an infection control concern.
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.
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