Failure to perform hand hygiene during wound care was observed for a resident with diabetes and a pressure ulcer. An LPN removed the old dressing and adjusted the resident’s incontinent brief, then acknowledged gloves should have been changed when moving from a dirty task to a clean task and that hand hygiene should have been performed before putting on clean gloves. The DNS stated staff were expected to follow infection control standards, including changing gloves as needed and performing hand hygiene when gloves were removed.
Infection control procedures were not followed during medication administration and wound-related care. An RN entered a resident’s room without hand hygiene, handled the resident’s cup and medications, and returned to the cart and computer without sanitizing hands. A CMA used a pill cutter without sanitizing it afterward and also entered and exited a resident’s room and accessed the med cart and computer without hand hygiene.
Staff failed to disinfect reusable lift equipment between resident uses and failed to perform hand hygiene while assisting multiple residents with meals. A CNA moved a mechanical lift and a ceiling-mounted lift between residents without cleaning them first, and during breakfast another CNA assisted two residents with food and a straw, touching a resident's face and returning to the first resident without sanitizing hands.
Surveyors identified unsanitary conditions in the laundry room, including a longstanding hole in the wall near washing machines, brown standing water behind the machines, and a black substance along the wall and floor. The housekeeping director reported that maintenance had been notified weeks earlier but repairs had not been made and could not identify the black substance. A cart of clean linen was placed near the standing water, and a blanket was observed partially submerged in the dirty water, which a laundry aide confirmed. The administrator later verified the standing water and black substance and was informed that water had been leaking onto the floor whenever the machines were used for several weeks.
An LPN failed to follow proper infection control practices while providing wound care to a resident with diabetes. The LPN did not change gloves or perform hand hygiene between treating multiple wounds, and only performed hand hygiene after leaving the room. The facility's infection preventionist confirmed that this practice did not meet the expected standards for glove changes and hand hygiene between wound sites.
A resident undergoing evaluation for TB was not consistently placed on airborne precautions as ordered. The resident participated in group therapy and communal activities without a mask, and staff frequently entered the shared room without PPE or following infection control protocols. The airborne precaution signage was incomplete, and staff were not fully aware of the required practices, resulting in a failure to implement proper infection control measures.
Staff did not follow Enhanced Barrier Precautions when handling a resident's feeding tube. Despite signage indicating the need for these precautions, an Interim DNS and an LPN were observed wearing only gloves, without gowns, while providing care to a resident with a gastric tube and GERD.
The facility did not monitor for legionella in its water system as required by its infection control policy. Maintenance staff had not been trained or instructed to check for water borne pathogens, and the Maintenance Director was unaware of at-risk areas and confirmed no monitoring had occurred. An LPN-Infection Preventionist also had not been involved in identifying or monitoring areas at risk for legionella.
Surveyors found that staff failed to follow infection control protocols during a COVID-19 outbreak, including leaving used COVID-19 tests in open areas, not performing required hand hygiene, and not adhering to proper PPE use and signage. A resident with chronic respiratory illness was on special droplet precautions, but staff did not consistently follow posted guidelines or infection prevention policies.
Staff failed to properly disinfect reusable medical equipment, including vital sign equipment and a community-use glucometer, between resident uses, and used personal care wipes instead of EPA-approved disinfectant wipes. An LPN did not clean a glucometer between residents until prompted by a surveyor. During meal service, a nursing assistant delivered food trays to multiple rooms and a family member without performing hand hygiene between rooms. These lapses were confirmed by supervisory staff and placed residents at risk for cross-contamination.
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