Staff failed to follow hand hygiene practices while caring for a resident with weeping, hot lower legs who had been started on antibiotics for cellulitis. One staff member removed TED hose from the resident’s weeping left leg and then immediately assessed the right leg without changing gloves or performing hand hygiene. Another staff member, after applying TED hose to the weeping leg while gloved, continued to handle the resident’s food, pillow, and personal items and answered a cell phone by placing her gloved hand into her pocket, all without changing gloves or performing hand hygiene, contrary to the facility’s hand hygiene policy.
Failure to follow infection control practices during a med pass affected two residents. An LPN prepared and administered meds while wearing gloves without hand hygiene, touched multiple potentially contaminated surfaces, changed gloves without hand hygiene, and entered residents' rooms after touching door handles without performing hand hygiene before medication administration.
Surveyors found that a resident on Enhanced Droplet Precautions for COVID-19 did not receive care consistent with posted PPE and hand hygiene requirements. Staff repeatedly entered and exited the resident’s room wearing only a face mask, without gowns, gloves, or eye protection, and did not perform hand hygiene between resident contacts. The PPE cart lacked gowns, no used gowns were found in the room trash, and the resident reported that staff did not always wear full isolation gear. Staff interviews revealed outdated or incomplete training on transmission-based precautions, misunderstanding of eye protection and Enhanced Barrier Precautions, and the facility could not provide documentation of current staff education despite having policies and CDC guidance requiring full PPE for COVID-19.
Staff did not consistently use Enhanced Barrier Precautions (EBP) or appropriate PPE when providing high-contact care to two residents with urinary catheters. In both cases, staff either failed to don PPE or only wore gloves despite clear facility policy and signage requiring EBP for residents with indwelling devices during transfers and toileting.
A staff member did not perform hand hygiene before entering a resident's room and failed to wear a gown while providing suprapubic catheter care, despite an Enhanced Barrier Precautions sign indicating the need for PPE. Another staff member was initially unaware of the reason for the EBP sign until reviewing the care plan, which specified precautions for catheter care.
A staff member did not perform hand hygiene before donning gloves and failed to disinfect a handheld glucometer between uses while conducting blood glucose monitoring for two residents. The device was placed on various surfaces and returned to storage without cleaning, contrary to facility policy and staff knowledge.
Staff failed to perform required hand hygiene before and during medication administration for multiple residents, including handling dropped medication and touching various surfaces and resident items without sanitizing hands or equipment, contrary to facility policy and infection control standards.
Staff did not consistently perform hand hygiene after assisting residents or while preparing and serving food, including serving coffee and feeding multiple residents without washing hands between contacts. Enhanced barrier precautions were not implemented for a resident with a chronic wound, as staff provided care without required PPE. Additionally, a staff member failed to follow glove use protocols during food preparation, using the same glove for multiple tasks and handling both food and soiled items.
Staff did not consistently follow infection prevention and control protocols during wound care, suctioning, and tube feeding for several residents. Observations included failure to perform hand hygiene, improper glove changes, and not wearing gowns as required by Enhanced Barrier Precautions. These lapses occurred despite staff awareness of facility policies and recent training.
Surveyors identified multiple infection control failures, including improper storage of medications and supplies, unclean medication rooms and refrigerators, and overflowing sharps containers. Staff did not follow proper hand hygiene or PPE protocols during wound and IV care for a resident, and environmental cleaning was lacking, with showers and utility rooms left soiled and supplies stored on floors. Staff interviews confirmed lapses in cleaning and supply management, and residents expressed concerns about cleanliness and wound healing.
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