Failure to Maintain Clean Technique During Wound Care: An RN performed wound care for a resident with PVD and cellulitis without setting up a clean field, placing wound supplies on the resident’s bed, dropping a dirty glove onto clean supplies, and failing to cleanse hands between glove changes. The DON stated the nurse should have used a clean field, discarded the dirty glove, and cleansed hands between glove changes.
Failure to follow EBP occurred when staff did not perform hand hygiene or wear a gown and gloves while assisting a resident with a wound during a transfer. The resident had dementia and a stage 4 pressure ulcer to the ankle, and the EBP sign at the door directed staff to clean hands on entry and exit and use gown and gloves for high-contact care such as transfers. The NA acknowledged not following these precautions, and the LPN, IP, and DON stated that gown, gloves, and hand hygiene were expected.
Surveyors found that the facility failed to implement Enhanced Barrier Precautions (EBP) in accordance with CDC guidance and facility policy for two residents who had central venous catheters (CVCs) for in-house dialysis. Both residents had physician orders for regular monitoring of their right chest CVC access sites and dressings, but there were no EBP orders in their records. In one case, EBP signage and PPE were posted at the room entrance, but a regional clinical leader stopped the use of PPE and stated the resident did not require EBP, explaining the setup was for an anticipated new admission. In an interview, the Regional Director of Clinical Services acknowledged that the facility does not follow EBP for residents with CVCs for dialysis, despite CDC recommendations that residents with indwelling medical devices, including central lines, be placed on EBP.
Surveyors found that biohazardous waste and sharps were stored in unlocked, unsecured rooms throughout the facility, including a memory care unit, despite a policy requiring sharps to be kept in locked, designated containers and areas. A room off the back entrance contained overflowing boxes and bags of infectious and biohazard medical waste with the door left partially open, and facility leadership acknowledged the room was unlocked and filled with biohazardous waste. On multiple units, surveyors observed overflowing sharps containers, an open sharps container with exposed needles, sharps containers placed on the floor, and IV lines with visible blood hanging from sharps containers, while residents were ambulating nearby. Facility representatives and the contracted waste vendor reported that biohazard waste removal services had been on hold for months due to non-payment, and records showed no licensed biohazard waste removal since that time.
During a norovirus outbreak, a resident with dementia and GI symptoms was placed on contact precautions with posted signage and a physician’s order requiring gown, gloves, and hand hygiene on room entry and exit. A nursing assistant entered and exited the resident’s room without wearing PPE, did not perform hand hygiene, then accessed a clean linen room and returned to the resident’s room still without PPE. The staff member later acknowledged knowing the resident was on contact precautions for norovirus and that she failed to follow the posted instructions, while facility leadership stated they expected staff to adhere to the contact precaution requirements.
A resident with a gastrostomy, requiring Enhanced Barrier Precautions (EBP), received care from two nursing assistants who did not wear gowns as mandated by facility policy. Despite clear signage and staff awareness of EBP requirements, video evidence and staff interviews confirmed non-compliance with gown use during high-contact care activities. The DON could not provide documentation of an effective infection control program related to EBP for this resident.
The facility did not obtain, review, or report ordered lab tests and failed to complete required COVID-19 testing for two newly admitted residents, resulting in delayed care and hospitalization for one resident with a UTI and COVID-19. Staff and leadership confirmed that physician orders were not followed and providers were not notified of abnormal or missing results during a COVID-19 outbreak.
The facility did not follow its water management program, failing to conduct required water testing, fixture flushing, and HVAC maintenance, as well as not documenting these activities. Multiple water samples tested positive for Legionella, and a resident with dementia and adjustment disorder was hospitalized with Legionella pneumonia after developing fever and sepsis. Staff confirmed that the water management plan was not followed, and required mitigation steps were not performed or documented.
A resident with ESBL in the urine had a physician's order for contact precautions, but a nursing assistant repeatedly entered the room without performing hand hygiene or donning required PPE, despite posted signage. The staff member was unaware of the precautions, and leadership confirmed the expectation for proper infection control measures.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
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