Staff failed to follow infection control practices during resident care and med administration. An ICP and an LPN provided wound care to a resident with a stage 3 neck pressure ulcer and EBP orders without gowns or gloves. An LPN failed to perform hand hygiene after handling a used glucometer before preparing insulin for a resident with DM, and an RN used the same BP cuff on two residents without cleaning it and did not perform hand hygiene between residents or before administering meds.
An LPN failed to properly clean and dry a resident’s nebulizer mouthpiece and medication cup after treatment, instead wiping the equipment with a paper towel and placing it in a plastic bag while still connected. The facility also had no monthly infection tracking and trending report for one month, and the ICP confirmed the missing report during review.
The facility failed to follow infection control practices during wound care, catheter care, and EBP. An LPN did not perform hand hygiene before or between glove changes while providing wound care to a resident with a stage 3 sacral pressure ulcer, and hand hygiene was done only after leaving the room. In another resident's room, the indwelling urinary catheter bag was observed on the floor on two occasions. A medication cart was also observed inside the room of a resident on EBP, even though the DON stated it should remain in the hall.
Hand hygiene was not offered to three residents during lunch tray service, including residents with severe or moderate cognitive impairment and ADL dependence. In a separate finding, an LPN unit manager confirmed that a resident with a neurogenic bladder and indwelling urinary catheter had an unsecured, exposed drainage evacuation tip hanging near the wheelchair wheel.
Staff failed to wear gowns and gloves when providing care to two residents on EBP. One resident had a dialysis port and received skin assessment, port care, and repositioning by an LPN and CNA who wore gloves but no gown. Another resident had wounds and a PICC line, and an AD and HA repositioned the resident in bed while wearing gloves only. Staff acknowledged the missed PPE use, and the DON, SDC/Infection Preventionist, and Administrator stated gowns and gloves were expected for this care.
Failure to Use PPE During Isolation Care and Medication Administration: Staff did not use required PPE during resident care and medication-related tasks. A CNA entered a resident’s room on droplet/contact precautions and handled a meal tray without PPE, an LPN performed PICC-related care and repositioning in the same room without appropriate PPE, an LPN administered G-tube medications in an EBP room without a gown, and another LPN gave a subcutaneous injection without gloves. The residents involved had diagnoses including ESBL UTI, influenza, chronic kidney disease, diabetes, dysphagia, and other chronic conditions.
Surveyors found that staff did not follow the facility’s infection prevention policies, including Enhanced Barrier Precautions (EBP), hand hygiene, and urinary catheter management. A respiratory therapist performed trach care and suctioning for two residents with tracheostomies without donning required gowns or masks, placed supplies and an inner cannula on the resident’s abdomen and linens, and left a room wearing contaminated gloves. An RN administered meds via a feeding tube for a resident with a gastrostomy, then performed eyelid scrubs without changing gloves or performing hand hygiene between routes of care and without using a gown despite EBP signage. CNAs delivered and set up lunch trays for three residents who required at least some assistance with hygiene or meals but did not offer hand hygiene before eating, contrary to policy. In addition, a resident with a urinary catheter was observed in bed with the drainage bag lying on the floor, rather than suspended from the bed as confirmed by nursing staff and the IP.
Failure to use EBP during PICC line medication administration: An RN administered an IV antibiotic through a resident’s PICC line without wearing a gown, despite the resident being ordered for EBP due to the PICC and osteomyelitis. Observation also found no EBP signage in the room, and both the RN and DON stated that PPE should have been used for the IV medication administration.
Infection prevention and control failures occurred during medication administration and catheter care for multiple residents. An LPN administered oral meds without hand hygiene, another LPN handled eye drops and blood pressure equipment without disinfecting items or performing hand hygiene, a third LPN failed to perform hand hygiene and disinfect an insulin pen after it touched a dirty bag, and a CNA emptied a resident’s catheter bag without the gown required under EBP. The DON confirmed the expected hand hygiene, disinfection, and PPE practices.
EBP was not followed for a resident on MDRO precautions. The resident had dementia, type 2 DM, depression, anxiety, moderate cognitive impairment, and was always incontinent of urine and bowel. During observation, a CNA entered the room, applied gloves, did not apply a gown, and provided incontinence care by changing the resident’s brief. The room had an EBP sign posted stating staff must wear gloves and gown for high-contact care activities, and the ADON confirmed the CNA failed to follow the facility’s infection control policy.
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