A treatment nurse performed wound care on a resident with a diabetic toe wound without following the facility’s hand hygiene policy. The facility’s policy required staff to wash hands after removing gloves and clarified that gloves do not replace handwashing. During the observed dressing change, the nurse removed the old dressing and gloves, did not perform hand hygiene, donned new gloves, cleansed the wound, then again removed gloves and applied new ones without hand hygiene before applying calcium alginate and a dry dressing. The nurse later stated she had not cleaned her hands between glove changes because there was no hand sanitizer available in the room and she did not wash her hands instead, and the DON confirmed that hand hygiene should have been performed between each glove change.
An LPN administered Humalog insulin to three residents and was observed drawing insulin from the vial without sanitizing the stopper first. The facility’s policy required medication administration in a manner that prevents contamination or infection, and the insulin insert stated the rubber stopper on multi-dose vials is not sterile and should be cleaned before use. The LPN confirmed the omission, and the DON stated vial stoppers should always be sanitized before insulin is extracted.
Hand hygiene was not maintained during wound care for a resident with a stage 4 sacrococcygeal pressure ulcer and a left knee abrasion. An RN changed gloves multiple times while treating both wounds but did not sanitize hands between glove changes or after glove removal, despite the facility policy requiring hand hygiene before moving from a soiled body site to a clean body site on the same resident and after glove removal. The nurse acknowledged she knew hand hygiene was required but forgot, and the infection control nurse confirmed the policy.
The facility failed to maintain infection control practices during medication administration and blood glucose monitoring. An LPN did not perform hand hygiene between resident contacts or before checking a resident’s blood glucose, and did not disinfect the glucometer after use. A second LPN also failed to perform hand hygiene before medication administration for another resident, and both LPNs confirmed the missed hand hygiene practices.
Staff failed to follow EBP during high-contact care for residents with an indwelling catheter or wound, including showering, incontinence care, and catheter bag emptying without gowns. During wound care for a resident with a right foot wound, an RN used the same gauze on two wounds, did not change gloves or perform hand hygiene between steps, and handled the dressing with contaminated gloves.
Staff failed to follow infection control protocols during incontinence care for two residents, including not performing required hand hygiene between glove changes and after contact with stool, and placing soiled items on clean linens. CNAs provided perineal care, handled residents’ clean clothing, body surfaces, wheelchairs, and room surfaces, and managed soiled briefs and pads without appropriate glove changes or hand sanitizing, contrary to facility policy. Both CNAs later acknowledged they should have performed hand hygiene and changed gloves correctly, and the DON confirmed that staff are expected to follow these infection prevention practices.
The facility failed to maintain an effective infection control program by not analyzing repeated PEG infections and repeated UTIs and by not following its system for identifying potential infections. An Infection Preventionist stated she did not determine the cause of the repeated infections or develop a plan to prevent future infections, and the DON confirmed the infections should have been analyzed monthly. For one resident with a urinary catheter and multiple medical diagnoses, cloudy, foul-smelling urine led to a U/A C&S order, but the specimen results were not followed up in a timely manner and nursing documentation showed no ongoing follow-up until the Infection Preventionist later located the lab results.
Failure to Follow EBP During Catheter Care: A resident with an indwelling urinary catheter was on EBP per orders, care plan, and posted room signage requiring gloves and a gown for high-contact care, including catheter care and hygiene. During observation, a CNA provided catheter care and peri care without wearing a gown, and later confirmed the PPE was not worn as required; the DON confirmed staff were expected to follow EBP for residents with urinary catheters.
Two residents with physician orders and care plans for Enhanced Barrier Precautions (EBP) during wound care did not receive care in accordance with the facility’s infection control policy. During separate wound care procedures, a treatment RN failed to wear a gown and did not change gloves between cleaning the wounds and applying ointments, powder, or clean dressings. The corporate RN confirmed that EBP requires staff to wear a gown and gloves for wound care and to change gloves after cleaning and before applying clean dressings or ointments.
The facility failed to follow its Enhanced Barrier Precautions (EBP) policy requiring gown and glove use during high-contact care for residents with wounds and indwelling devices. A resident with a stage 3 pressure ulcer and another resident with multiple lower extremity ulcers and an indwelling urinary catheter were on EBP, yet a treatment nurse performed wound care and a CNA emptied a urinary catheter and changed a brief wearing only gloves and no gown. In one case, EBP signage was missing from the door; in others, signage was present but not followed. The DON later confirmed that residents with wounds and urinary catheters should be on EBP and that staff should wear both gown and gloves for wound care and catheter care.
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