Failure to Follow EBP and Hand Hygiene Practices: Staff did not wear gowns or gloves, did not perform hand hygiene, and did not clean an EZ stand lift after providing high-contact care to a resident on EBP with a Foley catheter. Staff also provided toileting care to a resident with open stage II pressure ulcers without gowns, and a housekeeper handled resident-room surfaces and items with unclean hands while cleaning rooms. Facility policy required gown and glove use for EBP, cleaning reusable equipment between residents, and hand hygiene after resident contact and glove removal.
A resident with urinary retention, bladder disorder, and a suprapubic catheter was ordered to have twice-daily catheter flushes with normal saline and 5% vinegar. An LPN reported reusing a labeled graduated cylinder for the irrigation solution while only changing the syringe, despite facility policy requiring sterile equipment and the availability of sterile catheter kits. The DON acknowledged the container should be changed each time and that the resident had experienced UTIs, while a nurse manager training as the infection preventionist was unaware non-sterile cylinders were being used. The administrator stated the LPN had been educated on catheter kits and that nurses should understand sterile field requirements.
Housekeeping staff failed to follow hand hygiene and glove-use practices while cleaning resident rooms and did not follow the manufacturer’s required contact time for a Multi-Surface Peroxide cleaner. One housekeeper handled trash, cleaning supplies, and room surfaces with the same gloves on without hand hygiene between tasks, while another entered a resident room wearing gloves without hand hygiene and wiped surfaces immediately after spraying the disinfectant. The cleaner’s label required a 1- to 2-minute wait before wiping dry, and staff interviews showed uncertainty about the product’s disinfection contact time.
Surveyors found that the facility failed to implement a formal water management program for Legionella. The maintenance director maintained the in-line water heater at 117–118°F, below the 122–125°F range required for Legionella control, did not add chemicals for Legionella prevention, did not test building water for chlorine, and had no documented plan for flushing stagnant water in empty rooms. A city water employee confirmed chlorine testing was done only at an upstream site, not at the facility. The DON/infection preventionist and the administrator both stated they expected maintenance to follow federal Legionella guidelines, but the administrator acknowledged that staff turnover led to no monitoring, no formal process for flushing stagnant water, and no system to ensure appropriate water temperatures. The Infection Prevention and Control Policy in effect did not address Legionella management or prevention, creating a facility-wide deficiency with potential impact on all residents, staff, and visitors.
Staff did not consistently use required PPE, such as gowns and gloves, when providing care to residents on enhanced barrier precautions, and failed to clean shared equipment like mechanical lifts after each use. Multiple residents reported that staff typically wore gloves but not gowns, and urinals without lids were left in rooms. Additionally, a urine spill remained uncleaned for hours, and staff were unaware until notified. These actions did not follow facility infection prevention policies.
Staff did not consistently follow infection control protocols, including failure to wear required PPE when entering rooms under Enhanced Droplet Precautions, inadequate hand hygiene practices after glove removal and before resident care, and improper cleaning and disinfection of a shared glucometer used for multiple residents. Facility policy requiring individual, labeled glucometers for each resident was not followed, and staff did not have necessary cleaning supplies readily available.
Surveyors identified infection control deficiencies when a CMA failed to clean an inhaler after use, a CNA did not change gloves or perform hand hygiene between cleaning urine and handling a catheter bag valve, and another CNA did not remind a resident to wash hands after bathroom use. Facility policies for glove use and resident hand hygiene were also lacking.
Staff did not consistently use required PPE or perform hand hygiene during high-contact care activities for residents on enhanced barrier precautions, including those with indwelling devices, wounds, or infections. Multiple staff were observed providing care, handling soiled linens, and performing sterile procedures without following established infection control policies, leading to widespread noncompliance.
A resident's oxygen tubing was repeatedly observed on the floor and not replaced, contrary to facility infection control protocols. Staff interviews confirmed that tubing should be stored on the machine and replaced if contaminated, but these practices were not consistently followed.
A resident with an open surgical wound on the ear was not placed on enhanced barrier precautions as required by facility policy. Observations showed no signage or PPE available, and staff confirmed that EBP had not been implemented since the surgical procedure, despite the resident's ongoing wound care needs.
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