Failure to Follow EBP PPE Requirements: A resident with a wound and EBP order was observed receiving direct care from a CNA who wore gloves but did not don the gown required by the room signage. The CNA handled a urine-filled bedpan, emptied and rinsed it, and later stated she did not know whether a gown was required or whether she had seen the signage. The DON and Administrator stated staff should wear the appropriate PPE, including gowns and gloves, for direct care under EBP.
A resident with acute osteomyelitis, renal and perinephric abscesses requiring IV antibiotics was placed on enhanced barrier precautions with ordered isolation and twice-daily spinal wound care. Surveyors observed that there was no enhanced barrier precaution signage outside the resident’s room and that the ADON performed direct wound care without donning a PPE gown, contrary to the facility’s infection prevention and control policy requiring staff education and demonstrated competence in infection control practices. The DON reported that precaution signs are taped and believed the sign had fallen, while both the DON and Administrator stated their expectation that staff follow infection control signage and adhere to ordered precautions.
Failure to perform hand hygiene and glove changes during wound care. A resident with bilateral heel wounds, diabetes, HF, HTN, and lymphedema received wound care when the DON removed soiled dressings, then used the same gloves to handle sterile gauze, wound cleanser, and cleanse both heels without hand hygiene or glove changes between wounds. RN2 stated she would change gloves and perform hand hygiene between dirty and clean tasks, and the ADON/IP stated staff were expected to do so during wound care.
A cognitively intact resident with a urostomy and indwelling catheter system was observed on multiple occasions with the open-ended catheter tubing hanging into a trash receptacle, contrary to facility policies on infection prevention and catheter management. The resident reported emptying her own urostomy by attaching the catheter bag tubing to the pouch and placing the tubing over the trash can in case of leakage, and stated she did not perform hand hygiene before or after draining the bag and had not been provided with alcohol-based hand rub or sanitizing wipes. An LPN confirmed the resident’s self-care routine and, upon seeing the tubing in the trash can, acknowledged it was inappropriate and recognized the potential for UTI. The IP, DON, and ED each stated that the tubing being in the trash can was a concern and could lead to infection, indicating a failure to effectively implement the infection prevention and control program for this resident.
The facility failed to implement and maintain effective infection prevention and control practices, including missing Enhanced Barrier Precautions (EBP) signage for multiple residents with devices such as feeding tubes, colostomies, dialysis catheters, and indwelling urinary catheters, despite care plans and orders indicating EBP. Several residents receiving tube feedings had bottles and tubing hanging without dates or times and without protective end caps when not in use, contrary to staff statements that feedings should be dated, timed, and properly capped. Staff also did not consistently disinfect shared equipment and surfaces between residents, including a medication cart used for blood glucose checks, a blood pressure cuff used on more than one resident, and a mechanical lift that was returned to the hallway without cleaning after use, despite facility expectations and policies requiring cleaning between each resident.
Staff failed to follow infection control practices during resident care and routine tasks. An NA was observed wearing contaminated gloves in the hallway, entering multiple resident rooms without hand hygiene, and not removing PPE inside the room. Another NA passed ice and water by filling cups over the open ice chest and leaving the scoop on top of the ice, while moving between residents without hand hygiene. Leadership stated staff were expected to perform hand hygiene before and after resident contact, after glove removal, and to follow proper PPE and sanitary ice-handling practices.
Infection Prevention and Control Program Deficiencies: The facility failed to maintain an effective IPC program when hot water was kept below the level needed to prevent Legionella growth, the Water Management Plan lacked a required temperature range, and the IP/DON had not participated in developing the plan. The facility also had cloth aprons in the laundry rooms instead of impermeable PPE for handling heavily soiled linens, and clean blankets were observed stacked on the floor beside an overflowing linen cart.
Infection control practices were not followed across the facility. Staff were observed failing to perform hand hygiene before and after resident contact, between room entries, and after handling trays or resident items. A resident with ESBL history was not consistently placed on EBP, with no door signage and staff entering for direct care without gowns; one aide wore gloves but not a gown and did not clean hands when leaving. Surveyors also found dirty utility and shower room sanitation problems, no non-permeable gowns in the laundry area, and a nurse returned a glucometer to storage without cleaning or disinfecting it after a fingerstick.
A resident with dementia, Parkinson's disease, and a g-tube was observed receiving medications via the g-tube without the RN first donning a gown, despite EBP signage on the room door requiring gloves and gown for feeding tube care. The facility's infection control policy did not include specific EBP guidance, and interviews showed staff expected gown use for g-tube medication administration, though the RN said he forgot.
Staff failed to follow Enhanced Barrier Precautions (EBP) for two residents requiring infection control measures: one with a feeding tube and another with a sacral wound. In both cases, staff did not wear gowns during high-contact care activities, despite care plans and facility policy requiring EBP. Signage and PPE availability were inconsistent, and staff misunderstood or disregarded EBP requirements, resulting in noncompliance with infection prevention protocols.
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