Failure to Perform Hand Hygiene During Meal Service and Keep C-PAP Equipment Clean: An AD delivered and set up meal trays for four residents but did not offer hand hygiene to the residents or sanitize her hands between trays, despite facility policy requiring hand hygiene before serving food and between residents. In a separate finding, a resident’s C-PAP mask and tubing were observed resting on the bed with a brown substance caked inside the mask; the resident did not know when it was last cleaned, and an LPN and ADON confirmed the mask was dirty and needed cleaning.
Infection control practices were not followed for two residents on TBP and EBP. A CNA placed a soiled gown on the floor after assisting a resident on contact isolation, and an LPN failed to perform proper hand hygiene and did not wear a gown while providing care and administering medications via g-tube to a resident on EBP. The facility policy required gown and glove use for contact isolation and targeted gown and glove use for high-contact care under EBP.
Failure to Offer Hand Hygiene Before Meals: Staff failed to offer hand hygiene to two residents during meal service after setting up their trays. One resident had dementia, dysphagia, and needed help with personal care, while the other had diabetes, depression, and needed staff assistance with meal set-up. Facility policy and a Tidy Hands program required proper hand hygiene and assistance with handwashing before meals, and the CNA confirmed the omission. The DON stated hand hygiene was expected before meals and confirmed the infection control policy was not followed.
A facility failed to maintain infection prevention and control during catheter care and PEG medication administration. A resident with a chronic Foley catheter had the catheter bag touching the floor, and a CNA performed catheter care without the gown required by EBP. Another resident with a PEG tube received medications from an LPN who did not wear a gown, did not check tube placement or residuals, and removed gloves outside the room after handling the tube and syringe.
An LPN failed to wear the required PPE during medication administration through a resident's PEG tube. The resident had Alzheimer's, dementia, dysphagia, a feeding tube, and an order for EBP. During observation, the LPN wore gloves but not a gown while disconnecting the enteral tubing and giving alprazolam and water through the PEG tube; the DON stated staff should wear gown and gloves for this task.
Improper Infection Control During Medication Administration: An LPN handled a resident’s oral medications with her hands before placing them into a medication cup and administering them. The resident had multiple chronic conditions, including COPD, HF, DM, and chronic pain syndrome, and the DON confirmed staff were expected to follow infection control practices and not touch medications with hands.
An LPN failed to perform hand hygiene between glove changes during wound care for a resident with a stage 4 pressure ulcer, and another LPN did not wear an isolation gown while administering medication via PEG tube to a resident who was in EBP. The residents had significant medical needs, including dependence on staff care, a wound, and a feeding tube, and staff acknowledged the PPE and hand hygiene lapses.
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.
Infection Control Lapses During Medication Administration: An LPN failed to wear a gown while accessing a resident’s PEG tube under EBP, an RN did not perform hand hygiene after removing gloves following insulin administration, and an LPN did not clean reusable equipment after using a blood pressure cuff and pulse oximeter. The residents involved had diagnoses including dysphagia, diabetes, and cardiac conditions, and facility policy required EBP, hand hygiene, and cleaning of non-critical reusable equipment.
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.
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