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 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.
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.
Infection prevention and control failed when a resident with a surgical wound and external fixator did not have EBP signage or PPE available, and an RN performed wound care without maintaining a clean field, changing gloves, or performing hand hygiene between dirty and clean tasks. The RN also handled clean supplies with bare hands and left contaminated supplies in the room. In separate events, an LPN touched the medication cart and computer equipment, then administered medications and performed a blood sugar check for two residents without hand hygiene before or after care.
The facility failed to maintain infection control practices for two residents. One resident with a Foley catheter had the catheter bag observed on the floor instead of kept below the bladder and off the floor in a privacy bag, despite staff stating it should not be placed on the floor. A second resident receiving wound care had dressing removal followed by continued wound care without the LPN doffing dirty gloves, performing hand hygiene, and donning clean gloves before cleaning the wounds.
The facility failed to maintain an infection prevention and control program. Staff handled a resident’s feeding tube without the full EBP described in the report, including not using gowns and leaving the tube uncapped when not in use. Another resident who was ordered EBP for a catheter and wounds had no EBP sign or supplies observed in or outside the room. During lunch service, a CNA touched a resident’s food bare handed and also handled another resident’s sandwich bare handed.
Staff failed to follow Enhanced Barrier Precautions (EBP) for a resident with an NG feeding tube and significant comorbidities, including cerebral palsy, dysphagia, and severe protein-calorie malnutrition. Surveyors observed an RN reconnect an uncapped feeding tube that had been touching a metal IV pole while wearing only gloves and no gown, despite an EBP sign on the door. On another occasion, a speech therapist provided multiple PO trials and repositioned the resident while wearing gloves but no gown. In interviews, the RN, CNA Coordinator, and DON all confirmed that residents with feeding tubes require PPE, including gowns and gloves, when handling tube feedings or feeding the resident under EBP.
Infection prevention and control was not maintained when EBP was inconsistently implemented for residents with PICC lines, an NG tube, a chronic wound, and an indwelling catheter. Staff were observed using gloves without gowns, one RN exited a room without hand hygiene after handling a PICC line, and there was no EBP signage for some residents. Clean linens were also observed on the laundry room floor.
Blood glucose meters were shared among residents and were disinfected with alcohol prep pads instead of the manufacturer-approved CaviWipes process. An LPN and the DON described using alcohol wipes after each use, while the meter manual required cleaning and disinfection with CaviWipes and a wet contact time before air drying. Thirteen residents had blood glucose monitoring orders, including residents with diabetes and some with HCV or hepatitis C. The facility also had an outdated COVID-19 infection control policy in the binder, with leadership acknowledging a more current version should exist.
Failure to Use PPE for Contact Precautions, PICC Care, and EBP: Staff entered residents’ contact precautions and EBP rooms without the required gown, gloves, or hand hygiene, including during medication passes, brief care, meal delivery, and PICC line administration. An RN administered oral meds and IV antibiotics to a resident with a PICC line without PPE, and staff also entered another resident’s room on contact precautions without PPE. A CNA entered a resident’s room to change a brief without PPE even though the care plan required gown and gloves for EBP-related care.
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