Surveyors found that staff repeatedly failed to follow hand hygiene and Enhanced Barrier Precautions (EBP) requirements. CNAs and an LPN provided direct care, including incontinence care, use of a mechanical lift sling, and gastric tube feeding, without performing hand hygiene before or after care and without using required gowns for residents on EBP. One CNA handled a soiled lift sling, touched his hair and face, used a touchscreen to document care, and then assisted another resident without cleaning his hands. Another CNA entered an EBP room wearing only gloves, not a gown, and did not perform hand hygiene after removing gloves. An LPN handled a feeding tube and provided care to residents on EBP without hand hygiene or gown use. A resident’s representative reported seeing staff work with a feeding tube without gloves or a gown, while staff interviews and facility policy described correct practices that were not followed in practice.
A CNA failed to change gloves or perform hand hygiene during incontinence care, including when handling a resident’s vanity drawer and barrier cream, while another CNA returned supplies while still gloved. Staff also did not disinfect shared vital signs equipment between residents, and a CNA-medication aide did not disinfect a shared glucometer with the proper wipe contact time or after removing soiled gloves. Interviews showed inconsistent understanding of the correct infection control practices.
A resident with MDRO had concurrent physician orders for contact precautions and Enhanced Barrier Precautions, but the care plan did not specify the required isolation type, and no isolation signage or PPE was posted at the room. CNAs and an LPN were unclear about the resident’s MDRO status and whether PPE was required, with some believing precautions were no longer needed and others unsure what happened to prior isolation signs after a room change. The LPN discovered two conflicting isolation orders in the electronic record and had not yet contacted the DON or physician for clarification, while the DON later confirmed the resident had MDRO in sputum and that PPE should have been used, yet the facility’s process for placing and maintaining isolation signage and communicating precautions to staff had not been effectively carried out.
Failure to Follow EBP During High-Contact Care: Staff did not consistently wear gowns and gloves while providing direct care to residents on EBP. Observations showed an unidentified staff member assisting a resident with dressing and transfer without a gown, two staff transferring a resident with a foley catheter and colostomy bag without gowns, and RN/CNA staff providing transfers, toileting, and wound-related care to another resident without the required PPE. Interviews confirmed staff knew residents with wounds or indwelling devices were on EBP and that gowns and gloves were required for high-contact care activities.
The facility failed to follow infection control practices during housekeeping, resident care, and medication administration. Two housekeepers cleaned resident rooms without cleaning all high-touch surfaces, did not follow the required disinfectant dwell time, and used the same gloves after touching contaminated surfaces and resident items. For a resident on EBP with an open wound, urinary catheter, and PICC line, a restorative aide, CNA, and LPN did not consistently wear gowns for high-contact care and did not change gloves or perform hand hygiene after touching surfaces before continuing care. An RN also dispensed oral meds into a bare hand before placing them in a med cup.
Staff failed to follow infection control practices during resident care, including not wearing required gowns and other PPE for residents on EBP and contact precautions, and not performing hand hygiene during wound care after glove contamination. An LPN contaminated gloves while dressing a wound, multiple staff entered a room for a resident with shingles without the required PPE, laundry was sorted without proper protective equipment, and a contaminated nasal cannula that had been on the floor was placed back on a resident.
Staff failed to follow Enhanced Barrier Precautions (EBP) and hand hygiene requirements during care of multiple residents. In several instances, CNAs and an LPN provided wound care, incontinence care, and linen changes to residents on EBP using only gloves and no gowns, despite posted EBP signage and available PPE. During one wound dressing change, an LPN did not change gloves between removing a soiled dressing and preparing a new one. In another case, an RN administered tube feeding to a resident with a feeding tube while wearing gloves and a mask but no gown, and initially believed the resident was not on EBP. These events occurred despite facility policy and CDC-based expectations for gown and glove use during high-contact care activities and proper hand hygiene.
Surveyors identified multiple infection control failures involving hand hygiene, handling of drinkware and silverware, and mask use during a COVID-19 outbreak. CNAs refilled water pitchers and passed meal trays between residents without performing hand hygiene, including after directly handling a resident’s straw and assisting with dressing and food setup. Staff handled utensils by the tines and cutting surfaces, and cups by the rims, and used a knife that had just cut food to stir a resident’s coffee. During the same period, staff pulled masks down while in close contact with residents, wore masks below the mouth while assisting with meals, and did not perform hand hygiene after touching the outside of their masks, contrary to facility policy and CDC-based expectations.
Surveyors identified multiple infection control deficiencies, including improper hand hygiene, PPE use, and room disinfection. An RN administered a subcutaneous injection to a resident without performing hand hygiene between handling the med cart and the injection and did so without gloves, then later administered an oral medication that had fallen onto the med cart surface. During tracheostomy care for a resident, the same RN did not change gloves between removing a soiled inner cannula and inserting a clean one and did not use a gown or mask. In a separate observation, two CNAs and an RN provided high-contact care, including dressing, transferring, toileting, and wound care, to a resident with a Foley catheter and a buttock wound while only wearing gloves and not donning EBP gowns. Housekeeping staff were also observed spraying disinfectants on toilets, sinks, grab bars, and bedside tables and immediately wiping them dry, failing to meet required chemical dwell times and not fully disinfecting high-touch surfaces.
The facility failed to follow infection control practices for insulin administration when an LPN used one resident’s Lantus insulin pen to inject another resident, despite CDC guidance and facility policy stating insulin pens are for single-patient use only. The affected resident had type 2 DM, chronic kidney disease, and dementia with severe cognitive impairment and required assistance with ADLs. When the ordered insulin was not found in the emergency kit, the LPN used another resident’s pen instead of obtaining the medication through STAT pharmacy delivery or nearby hospitals, resulting in noncompliance with established infection prevention standards.
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