Expired hand sanitizer was found in many resident rooms, a linen cupboard lacked a covering to protect linens from airborne infectants, and a resident’s wheelchair had torn, dirty padding. Staff also failed to consistently follow EBP and hand hygiene during personal hygiene and wound care for residents with pressure ulcers, including not cleansing a wound before dressing it and bringing wound care supplies into multiple rooms without sanitizing equipment between residents.
Staff failed to follow infection control practices during resident personal care and catheter care. CNAs and an RN used the same gloves across dirty and clean tasks, touched resident personal items and bedside surfaces after perineal care, and did not clean catheter tubing during one resident’s care. Reusable mechanical lifts were also observed with debris, damaged surfaces, and missing parts, and were returned to the hallway without being disinfected after resident use.
Urinary catheter bags for a resident with a kidney transplant, CKD, and urinary retention were observed stored in the resident’s bathroom shower without caps over the tubing connectors and without dates showing when they were last used. One bag was on a shower bench and another was hanging on a handrail near a toilet, and a syringe used for cleaning was also present. Staff and the IP confirmed that an uncapped bag stored next to a toilet would be considered contaminated, and the facility policy did not clearly define when the cleaning syringe should be changed or who should do it.
A CNA wore two pairs of gloves while assisting a resident with incontinent care and, with potentially soiled gloves, touched the resident’s wardrobe and retrieved clean clothing before removing the gloves. The CNA said this was a normal practice at the facility and confirmed she did not remove the outer gloves after peri-care. The DON stated this was not the facility’s normal practice and that staff were expected to remove soiled gloves and perform hand hygiene before touching clean clothes or the wardrobe; the PPE policy did not address double-gloving, and the hand hygiene policy required hand hygiene after glove removal.
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.
Infection Control and Environmental Cleaning Failures: Staff did not follow whirlpool disinfection instructions, as a CNA did not know how to flush the whirlpool jets and the tub was later observed with standing water, suds, hair, and a dry scrub brush left in the room. Staff also did not promptly clean bowel movement from two residents’ bedroom floors and soiled linens/clothing were observed in one resident’s room before the area was later cleaned.
Staff failed to follow infection control practices during blood sugar testing, medication prep, and wound care. An RN used the same gloves while handling the computer, glucometer supplies, and a resident’s finger stick, and later acknowledged she should have removed the gloves and performed hand hygiene first. A CMA touched medications with taped fingers that were uncleanable, and an RN performing wound care did not wear a gown despite enhanced barrier precautions requiring gloves and a gown for wound care.
Staff failed to follow infection control practices for residents on EBP and during catheter and skin care. Two residents with indwelling devices did not have PPE supplies or EBP signage available as expected, and staff interviews showed the resident care information had not been updated consistently. During care for a resident with a Foley catheter and open skin areas, a CNA reused contaminated gloves while cleaning the catheter tubing and nearby skin, and an LPN did not perform hand hygiene before putting on clean gloves to apply powder.
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