Surveyors found that staff failed to follow infection control practices during PEG tube and wound care. Two residents with PEG tubes had sites with visible brown, crusted or yellowish drainage that had not been cleaned for several days, despite physician orders for daily cleansing and, when indicated, dressings. In another case, a CNA provided peri-care for stool and then assisted with a stage IV sacral pressure ulcer dressing change without changing gloves or performing hand hygiene, contrary to facility policy and staff expectations for aseptic technique.
Infection control practices were not followed during meal service, medication administration, and biohazard waste storage. Staff passed meal trays to multiple residents without hand hygiene between rooms, including after contact with another resident in the hallway. An RN administered meds to a resident with dysphagia via PEG tube while using the same gloves after resident contact, handled meds with gloved hands, and brought the med cart into the room. Unsecured biohazard waste containing used gowns, gloves, and needles was also observed outside the locked biohazard room, and the room key was left accessible.
A CNA failed to follow EBP and hand hygiene requirements during high-contact care, including providing peri care without a gown for a resident on EBP and not sanitizing or washing hands before care for another resident. A resident who self-suctions was observed using exposed suction equipment that was not protected in a bag, while the DON stated nursing was responsible for changing and cleaning the tubing and device. The DON and IP nurse confirmed the residents were placed at increased risk for infection.
Staff failed to follow hand hygiene and EBP during wound care and peri care for a resident with a stage 3 sacral pressure ulcer. An RN and the IP nurse were observed missing hand hygiene before glove use, leaving and re-entering the room while handling supplies, and performing peri care without a gown. The RN, IP nurse, and DON all confirmed the hand hygiene and gown use lapses during direct care.
Failure to maintain an effective infection prevention and control program occurred when the DON, who also served as the Infection Preventionist, did not have sufficient time to complete infection surveillance, track and trend infections, or conduct infection control rounds for several months. Facility policy required surveillance, reporting review, and periodic IC rounds, but no infection surveillance logs or IC meeting minutes were available, and the DON stated she was occupied with staffing, scheduling, the med cart, and nursing supervisor duties.
The facility failed to maintain infection control practices when an LPN and RN/IP confirmed oxygen tubing was not bagged or changed as required, a CNA did not perform hand hygiene or complete peri-care before applying a clean brief, and a staff member touched a resident’s food with a bare hand while setting up a meal tray. The residents involved included one who used oxygen as needed, one who was dependent on toileting and hygiene and had a history of UTIs and a pressure ulcer, and one with severe cognitive impairment and malnutrition.
Failure to use EBP during high-contact care and to keep Foley catheter tubing secured and off the floor. A resident with a suprapubic catheter received catheter care from CNAs without EBP despite an order for it; another resident with a PEG tube had medication administration performed by an LPN who forgot to wear a gown; and a third resident with a Foley catheter was repeatedly observed with tubing unsecured and touching or dragging on the floor, which the DON acknowledged as an infection control concern.
A resident with multiple unstageable pressure ulcers and moderate cognitive impairment had an active order for Enhanced Barrier Precautions (EBP) related to wounds. Facility policies required wound care to be provided in a manner that prevents infection and cross-contamination, and EBP signage with required PPE was posted on the resident’s door. Despite this, an RN performed wound care to open ankle and heel wounds without donning a gown, even though PPE was available and the RN had recently completed wound care competency training. Leadership, including the DON and Staff Development Coordinator, confirmed expectations that staff follow current infection control standards and use appropriate PPE for residents on EBP.
Infection control practices were not followed when a clean utility cart was left uncovered with clean supplies exposed and resident gowns on the bottom shelf touched the floor. Staff also entered a room with EBP and contact isolation signage without wearing gowns, and one aide carried soiled linen against her body without a barrier bag. The IP and DON confirmed that clean linen carts must be covered and that staff caring for residents under EBP or contact precautions are required to wear a gown.
The facility failed to properly disinfect a glucometer after use when an LPN wiped the front and back of the device and stored it immediately instead of keeping it wet for the required contact time. The facility also failed to place a resident with an ESBL urine culture result on contact precautions; the DON and an LPN confirmed the diagnosis and that precautions were not in place. The resident had COPD listed among the admission diagnoses.
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