Failure to Offer Hand Hygiene During Meal Service: A CNA delivered meal trays to three residents, set up each meal, and did not offer hand hygiene before the meal service. The residents had diagnoses including muscle weakness, dysphagia, malnutrition, hypotension, diabetes, and anxiety, and each required staff assistance with meal setup; two were cognitively intact and one had moderate cognitive impairment. The CNA confirmed the omission, and the DON stated hand hygiene was to be offered prior to meals.
An infection control deficiency occurred during medication administration for a resident with Cerebral Palsy, dysphagia, and a G-tube. An LPN carried prepared medications uncovered through the facility, did not wash hands before donning gloves, administered the meds via G tube, and did not clean the resident's tube feeding before restarting it; the LPN and DON both confirmed the expected practices.
A resident with a PEG tube did not have EBP included in the care plan, order summary, CNA task list, or room signage. During care, an RN administered medication via the PEG tube wearing gloves but no gown, and a CNA stated she did not wear a gown for incontinence care, dressing, or linen changes. The DON and IP confirmed gowns were required for these close-contact care activities.
Staff failed to follow infection control procedures during medication administration for two residents on EBP. An LPN gave PEG medications to a resident with a gastrostomy without wearing a gown, and an RN administering glaucoma eye drops to a resident with severe cognitive impairment touched the bottle tip to the eyelid and returned the contaminated bottle to the med cart without cleaning it. The DON confirmed the gown and eye-drop practices were incorrect.
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.
Failure to Provide Hand Hygiene During Meal Service: Staff failed to offer hand hygiene to three residents before lunch and did not sanitize their own hands before or after setting up meal trays. One CNA delivered trays to two residents, and another CNA delivered a tray to a resident, while the residents had diagnoses including DM, dementia, Parkinson disease, muscle weakness, and visual loss; the IP confirmed hand hygiene was to be offered before meals and performed between residents.
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.
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