Failure to implement EBP for two residents with chronic wounds and wound-related care needs. One resident with a chronic foot ulcer and another resident with multiple open skin areas and chronic leg, shoulder, and buttock wounds had no EBP signage or PPE available in their rooms, and staff interviews showed inconsistent understanding of the EBP orders. CNAs reported providing care with only gloves or without gowns, while the RDCS confirmed both residents should have been on EBP with gown and glove use for high-contact direct care.
Hand hygiene was not consistently performed during meal service, with CNAs observed touching residents and surfaces, delivering trays, and repositioning residents without changing gloves or cleaning hands. EBP was not implemented as ordered for residents with indwelling devices, as PPE and signage were missing or not used consistently, and staff showed inconsistent understanding of gown, glove, and mask requirements. The facility also stored PPD solution in a medication refrigerator at temperatures below the manufacturer’s required range, making the TB screening process for new admits inaccurate.
Infection control deficiencies were identified involving a resident on EBP for wound care, a meal-time cross-contamination event between two residents, and an uncapped tube feeding setup for a resident receiving enteral nutrition. Observations and staff interviews showed missing EBP signage and PPE at the resident’s door, a resident using a fork already used to feed herself to mix butter into another resident’s food, and disconnected feeding tubing left uncapped while formula remained in the bag. The DON and IP described the facility’s infection control protocols for EBP, meal assistance, and capping disconnected feeding tubing.
The facility failed to document an annual review of its IPCP. The Infection Prevention and Control Policy stated the plan would be reviewed annually and updated as needed, but when the DON was interviewed, documentation showing the last review was requested and not provided.
Staff failed to follow infection control practices during medication administration and did not maintain organized infection surveillance documentation. An LPN was observed handling an oral medication with bare hands before administering it to a resident, contrary to the DON’s stated expectation that pills be dispensed directly into medication cups without hand contact and that any contaminated dose be discarded. Additionally, the DON, who also served as the Infection Preventionist, reported that several residents had influenza during a past holiday season but had no list of affected residents or rooms, and the requested infection control surveillance logs and a formal tracking system were not available.
A resident with chronic wounds and multiple comorbidities received wound care without EBP, with staff entering without gowns, failing to perform hand hygiene at key points, and cleansing wounds in a back-and-forth manner across the wound bed. The dressing was not labeled and dated, and the facility also repeatedly transported uncovered coffee through the hallways to resident rooms during meal service.
Failure to Use EBP During Wound Care: A resident with an open wound and ordered daily wound treatment did not have EBP signage or PPE available outside the room, and an RN performed wound care using gloves and hand hygiene but no gown. The RN stated she did not think the resident needed EBP because the wound was healing, while the DON stated EBP should be used for residents with open wounds and that gown and gloves are required for high-contact care such as wound care.
A facility failed to maintain infection prevention and control practices during resident care and dining. A resident with a central venous catheter had no EBP signage observed, staff gave conflicting information about whether EBP was required, hand hygiene was not performed between glove changes during wound care for a resident with buttock wounds, and a CNA touched a chair and then the resident's food with the same gloves during meal assistance.
Infection prevention and control was deficient when staff did not consistently use PPE for residents on EBP and did not perform hand hygiene during wound care. A resident with a stage 3 pressure wound had wound care performed without gowns by the NP and UM despite EBP signage and PPE being present. Another resident on EBP for a surgical wound received direct care from an OT wearing gloves but no gown, and a third resident’s wound care included multiple glove changes without hand hygiene between dirty and clean steps.
Improper handling of soiled linens and failure to review IPCP policies: A CNA entered an influenza isolation room without the required eye shield, removed soiled linens in a red bag, and transported them without placing the bag into a clean bag. Laundry staff reported handling soiled linens with gloves only, with no gowns available in the soiled linen room, while the DON/IP and ADM described use of sugar bags and red bags for isolation laundry. The facility also had an IPCP policy with a 10/22 review date, and leadership stated the IPCP had not been reviewed or updated.
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