Staff failed to consistently implement and follow Enhanced Barrier Precautions (EBP) during wound care for two residents. For a resident with an indwelling urinary catheter and an EBP order, an RN and a CNA removed their gowns after catheter care and performed a heel and toe dressing change wearing only gloves, despite a door sign requiring gown and gloves for wound care and other high-contact care. For another resident with multiple open leg wounds and active wound care orders, an RN and a nurse aide performed dressing changes with gloves only, without gowns, and there was no EBP signage or order in place. Interviews with nursing staff, the IP, and the DON revealed inconsistent understanding and application of the facility’s EBP policy, which requires gown and gloves for high-contact care activities, including wound care and device care, for residents with chronic wounds or indwelling devices.
The facility failed to implement its infection prevention and control program when a nurse provided incontinence and skin care to a resident with chronic conditions without performing hand hygiene between glove changes and while using double gloves, contrary to CDC and facility policy that gloves are not a substitute for hand hygiene. In a separate case, another resident with neurologic deficits and muscle weakness had an IV site with a transparent dressing that remained in place despite visible dried and wet blood beneath it after completion of IV antibiotics, contrary to CDC guidance and facility expectations that soiled IV dressings be changed.
A resident receiving IV meropenem via a PICC line for septic shock related to a UTI had an active care plan and door signage requiring enhanced barrier precautions, including use of gown and gloves for high-contact care and device care to reduce MDRO transmission. During an observed medication administration, an LPN performed hand hygiene, donned gloves, accessed and flushed the PICC line, and administered the antibiotic without donning a gown, later stating she had forgotten to do so. The IP confirmed that a gown was required before administering the antibiotic, and this failure created the potential for infection spread.
Staff failed to consistently follow hand hygiene and PPE requirements for a resident on Enhanced Barrier Precautions (EBP) with an indwelling urinary catheter and PEG-tube. A CNA exited the resident’s room after incontinence care without performing hand hygiene after removing PPE, later handled the resident’s catheter and performed dressing tasks without prior hand hygiene or donning a gown as required by the EBP signage, and entered the room with another CNA for a hoyer lift transfer without either performing hand hygiene upon entry. An LPN performed hand hygiene and donned PPE before medication and nutrition administration via PEG-tube but then touched the sink and water while preparing supplies and did not change gloves or perform hand hygiene before accessing the PEG-tube. These actions did not comply with the facility’s hand hygiene policy and posted EBP instructions and created the potential for infection due to cross contamination.
Surveyors found that residents were served meals in the dining room without being offered required hand hygiene before eating, despite facility policy mandating handwashing or alcohol-based hand rub use before handling food. A CNA and the DON both acknowledged that residents’ hands should have been sanitized prior to meals. Additional observations showed a housekeeper transporting clean gowns uncovered in a hallway and significant visible buildup of white and grey fuzzy substances on pipes, wires, equipment, and chemical buckets in the laundry area, with the housekeeper stating there was no formal cleaning schedule in place.
Staff failed to follow infection prevention and control practices during medication administration and wound care. An LPN administered medications to two residents without performing hand hygiene upon entering their rooms, only cleaning hands after leaving, despite facility expectations for hand hygiene on room entry and exit. A resident with chronic wounds, MDRO risk, and orders for Enhanced Barrier Precautions received wound care from an RN who did not wear a gown, contaminated gloves by handling the bed controls and bed surfaces, placed wound-care supplies directly on the bed, used unsanitized scissors taken from a pocket, and reapplied gloves without performing hand hygiene.
The facility failed to follow infection control policies for oxygen and respiratory equipment and for disinfection of a shared glucometer. Multiple residents’ CPAP/BIPAP/VPAP masks, nebulizer masks, and oxygen tubing were observed uncovered on dressers, walkers, wheelchairs, and on the floor, rather than cleaned and stored in labeled bags as required. In one case, an RN placed oxygen tubing that had been on the floor directly into a storage bag without cleaning. A resident with COPD, depression, and cardiomegaly, ordered to receive continuous oxygen via nasal cannula, had the cannula picked up from the floor and reapplied by a CNA instead of being replaced. An LPN used a glucometer on a resident and wiped it with a disinfecting wipe but did not ensure the device remained wet for the full required contact time before returning it to its case, despite acknowledging the stated 2-minute dry time.
During an Influenza A outbreak, staff failed to follow required infection prevention and control practices for PPE and droplet precautions. A CNA entered a droplet‑precaution room with inadequate PPE, handled urinals without proper hand hygiene, and returned shared goggles to a storage bin without sanitizing them. An SDC cleaned multi‑use goggles but did not allow the required disinfectant contact time before returning them to the bin. An Activities Assistant moved consecutively between influenza‑positive and negative rooms offering coffee and activities, performing hand hygiene but not changing her mask or wearing a gown, while droplet precautions were in place requiring full PPE including mask, gown, eye protection, and gloves.
Surveyors found that the facility failed to follow its IPCP requirements for appropriate storage and handling of medical equipment when a resident’s power wheelchair, with personal items and a Hoyer sling, along with a resident lounge shower chair, a Hoyer lift, and a bariatric shower chair, were stored in an Out of Order shower room that was visibly soiled with a dirty toilet, brown substances on floors and walls, and used paper towels on surfaces. The Infection Preventionist acknowledged that staff should not be storing resident equipment in this Out of Order shower room.
Staff failed to follow infection prevention and control practices during blood glucose monitoring and environmental cleaning. An RN performed a blood glucose check and handled insulin pens for a diabetic resident by placing the glucometer and insulin pens directly on the resident's bed surfaces without using a paper towel barrier, contrary to AHCA guidance and facility expectations. In a separate incident, a CNA cleaned a urine spill from a leaking urinary catheter bag in a common area by covering and wiping it with a dry towel while wearing gloves, but did not clean or disinfect the area afterward, despite CDC procedures requiring thorough cleaning and disinfection of body fluid spills.
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