Surveyors found that a nurse responsible for wound care and infection prevention failed to follow basic infection control practices while treating two residents with pressure ulcers and one with a suprapubic catheter. The nurse repeatedly handled keys, a phone, and a computer, then accessed and prepared wound supplies without performing hand hygiene, touched gauze with ungloved hands before using it on a wound, and set up supplies on non‑impervious paper towels next to personal items instead of on a properly disinfected, protected surface. During one observation, the nurse cleaned a hip pressure ulcer and then a suprapubic catheter site using separate gauze cups but without changing gloves or performing hand hygiene between dirty and clean tasks, and then applied dressings after glove removal without washing hands. Facility policies required clean technique, use of an impervious barrier, handwashing between dirty and clean steps, and labeling dressings, but these were not followed, and the nurse and leadership acknowledged that the nurse had not received formal wound care training from the facility.
An LPN performed wound care for a resident with pressure ulcers and changed gloves during the procedure without performing hand hygiene between glove changes. The resident had diagnoses including Parkinson’s disease, psychotic disorder, and pressure ulcers, and required substantial to maximal assistance with personal care. The DON and Administrator stated hand hygiene should be performed with each glove change, and the facility policy required washing hands after removing gloves.
Failure to Follow EBP During G-Tube Medication Administration: A resident with an indwelling catheter and feeding tube was on EBP, with orders and a care plan requiring gown and glove use for high-contact care. During G-tube medication administration, an LVN used gloves but did not don a gown, and the LVN’s sweater touched the resident’s bed while disconnecting the feeding tubing and preparing medication. The LVN, IP, and DON all confirmed that gown and gloves were required for this type of direct care.
A resident with MRSA colonization and a PICC line for IV antibiotics experienced multiple breaches in infection control by nursing staff. An LPN repeatedly double-gloved, handled room surfaces, trash can lids, and the medication cart, then donned new gloves without performing hand hygiene before preparing and administering oral and IV medications. During PICC access, the LPN wiped the access port for only a few seconds, allowed IV tubing to touch bedding, let the access port fall onto the resident’s arm, and then re-accessed the line without hand hygiene or glove changes. At another time, the PICC site was left uncovered while a treatment nurse prepared for a dressing change, and the LPN entered without prior hand hygiene, disconnected IV tubing, and flushed the line after only a brief alcohol wipe. Staff interviews showed uncertainty and inconsistency regarding required scrub times, glove use, and dressing change schedules, which conflicted with facility policies and stated expectations for aseptic PICC care and hand hygiene.
Multiple residents with cognitive and medical impairments developed persistent rashes over several months, which were later identified as scabies in several cases. Despite ongoing symptoms and spread across different rooms and floors, the facility did not implement isolation, PPE, or enhanced cleaning until after a confirmed scabies diagnosis. Staff and housekeeping reported inconsistent communication and lack of infection control measures prior to this, resulting in a significant outbreak.
Staff failed to follow infection control protocols during wound care for a resident with a surgical wound, including not using barriers, reusing gauze, and improper glove changes. Additionally, two glucometers used for blood sugar checks on multiple residents were not disinfected according to manufacturer guidelines, as an LPN used alcohol pads instead of the required germicidal wipes.
A nurse failed to remove and discard PPE before leaving the room of a resident on Enhanced Barrier Precautions for a hip incision infection and a urinary drainage device. The nurse exited the room wearing gloves and a gown to retrieve supplies, then disposed of the gown in the hallway, contrary to infection control protocols. Both nurses involved acknowledged that PPE should be discarded inside the room to prevent cross-contamination.
A CNA did not perform hand hygiene before or after assisting a resident with incontinence care and continued to wear contaminated gloves while handling clean clothing and touching various surfaces. Soiled clothing was placed on the floor instead of in a trash bag, contrary to facility policy. Interviews confirmed staff were instructed on proper procedures, but these were not followed during the observed care.
A CNA failed to change gloves and perform hand hygiene during incontinence care for a dependent resident with severe cognitive impairment. The CNA handled clean items and applied cream to the resident's perineal area while wearing contaminated gloves, contrary to facility protocols and infection control policies. Staff interviews confirmed that proper hand hygiene and glove changes were expected but not performed in this instance.
A resident with a physician's order for contact precautions due to ESBL was assisted by a CNA who failed to use required PPE when entering the room and during direct care, despite clear signage and available supplies. The CNA only donned PPE after realizing the oversight, and also removed a lunch tray from the room without following isolation protocols. Facility staff interviews and policy reviews confirmed the expectation for PPE use, but the required infection control measures were not followed.
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