Staff failed to follow infection prevention and control policies when handling reusable equipment and soiled linens for two residents, including one on enhanced barrier precautions (EBP). A CNA removed a full body mechanical lift from a resident’s room without disinfecting it, despite facility expectations for cleaning after each use. In a separate incident, CNAs entered the room of a resident on EBP wearing only gloves initially, and one CNA placed soiled linens on the floor instead of directly into a bag, even after donning a gown. An RN later confirmed that staff were expected to disinfect lifts after every use, avoid placing soiled linen on the floor, and wear gowns upon entering EBP rooms.
Staff failed to follow infection control practices during resident care and medication tasks. A CNA did not use gown and gloves as required during toileting and catheter-related care, another resident with MRSA and multiple wounds did not have EBP in place during brief care and transfer, and a CNA touched equipment and other items without proper hand hygiene or glove changes during EBP care. A nurse also moved from dirty to clean wound care without changing gloves or performing hand hygiene, gave oral meds and eye drops without changing gloves, and prepared insulin pens without disinfecting the rubber stoppers.
Surveyors found that staff failed to follow the facility’s hand hygiene policy and proper glove use during a wound dressing change and multiple episodes of personal and toileting care. A nurse performing a dressing change did not remove soiled gloves after disinfecting a bedside table and did not perform hand hygiene between glove changes while cleansing and redressing a wound. In separate observations, CNAs providing perineal care, toileting assistance, and hygiene for two residents repeatedly removed soiled gloves and donned clean gloves without performing hand hygiene, and continued dressing, repositioning, and transferring the residents without required hand cleansing between glove changes.
Infection control standards were not followed during high-contact care for multiple residents. CNAs provided toileting, brief changes, hygiene, and transfer assistance without gowns for residents on EBP, and another CNA applied PPE without hand hygiene before emptying a urine drainage bag and did not disinfect the floor after a urine spill. An admin nurse confirmed the expected PPE, hand hygiene, and spill cleanup practices.
Staff failed to follow infection control practices during care for a resident and in the laundry room. A CNA removed a soiled brief, completed perineal care, and then applied clean brief and shorts without removing gloves or performing hand hygiene after contact with body fluids. In the laundry area, clean linen was left uncovered while soiled linen was transported past it and placed in washing machines, despite policy requiring clean and contaminated linen to remain separate.
Infection control standards were not followed during dressing changes for two residents. One resident on EBP for a suprapubic catheter with chronic cellulitis and wound drainage had a nurse perform glove changes without hand hygiene and without a gown, while also handling wound supplies without hand hygiene. Another resident with a right heel pressure ulcer had dressing supplies, including gauze, scissors, tape, and cleaning solutions, placed directly on a cloth chair instead of a clean surface.
Infection control and prevention standards were not followed for two residents on EBP for indwelling devices. A nurse caring for a resident with an ileostomy and indwelling catheter removed dressings and reapplied gloves twice without hand hygiene, while also handling a pen from a uniform pocket during care. A CNA caring for a resident with an indwelling catheter drained the catheter bag and then transported the resident in the same soiled gloves without removing them or performing hand hygiene. Facility policy required hand hygiene before and after care, after glove removal, and after handling catheters or urine.
Infection control standards were not followed for two residents during direct care. A CNA emptied a resident’s urinary catheter collection bag without applying a gown as required for EBP, and during incontinent care for another resident, a CNA cleansed the perineal area and then applied barrier cream without changing gloves or performing hand hygiene. Facility policy required gowns and gloves for high-contact care and hand hygiene before moving from a soiled body site to a clean body site on the same resident.
Staff failed to follow hand hygiene and glove-use standards during toileting care for two residents and during medication preparation for one resident. CNAs used the same gloves across multiple tasks, including incontinence care, transfers, and handling resident items, without washing hands between glove changes, and a medication aide handled a pill with a bare finger without performing hand hygiene or using gloves.
Infection control practices were not followed for two residents. A CNA assisted a resident on EBP with toileting without wearing a gown during high-contact care, and an RN administered medications to another resident without performing hand hygiene before glove use, after removing gloves, or before exiting the room.
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