Two residents on contact isolation or Enhanced Barrier Precautions (EBP) did not receive care in accordance with posted PPE requirements and facility policy. One resident with MRSA and multiple antimicrobial-resistant infections had contact isolation and EBP signage and an isolation cart with PPE at the door, yet an LPN entered and remained in the room without donning a gown or gloves, despite acknowledging the resident’s contact isolation status. Another resident on EBP related to a condom catheter had door signage directing staff to wear gowns and gloves for direct care, but a CNA twice provided dressing assistance and peri-care while wearing only gloves and no gown, later stating he had forgotten to don the gown. The DON confirmed the first resident should have been on contact isolation with gowns and gloves used upon room entry, and the Infection Preventionist confirmed that EBP was not appropriate for the first resident and that staff are expected to use gowns and gloves for residents on EBP during direct care, consistent with the facility’s EBP policy.
A resident’s nasal cannula tubing and CPAP mask were observed on the floor on two occasions, rather than stored in a clean, covered manner as required by facility policy. A CNA reported finding the equipment on the floor at the start of her shift and stated she had informed the charge nurse and requested appropriate storage supplies. An RN and an LPN both acknowledged the equipment should not be on the floor and should be kept in labeled bags, while the DON stated the resident was known to remove his oxygen and was unaware that the tubing on the floor was attached to an oxygen concentrator used at bedtime. The facility’s respiratory care policy requires safe storage, covering of oxygen cannulas and masks when not in use, and clean, labeled storage for CPAP equipment, which was not followed in this case.
Infection control practices were not followed for two residents on contact precautions and during medication administration for another resident. A CNA entered a room under contact precautions without gown or gloves, and a staff member entered another contact precautions room without hand hygiene or PPE before handling meal trays. In addition, an RN administered oral meds, eye drops, and an injection without changing gloves or sanitizing hands between tasks, despite facility policy requiring hand hygiene and glove changes.
Staff failed to follow contact precaution requirements when entering a resident room posted for transmission-based precautions. A staff member was observed inside the room wearing only a KN95 mask, without the required gown and gloves, despite signage instructing use of these PPE items before entry. The unit manager confirmed that the expectation is for staff to wear a gown and gloves in such rooms, and the staff member acknowledged prior education that these PPE components are required. The facility’s written policy on transmission-based precautions also specifies that a gown and gloves must be worn when indicated by the type of isolation, indicating noncompliance with established procedures.
A RN used the same BP cuff and monitor on two residents without disinfecting the equipment between uses, and later used it again on another resident without cleaning it before or after use. In a separate observation, a housekeeper/laundry aide moved a bin of soiled laundry through the clean side of the laundry room instead of using the soiled-laundry entrance, contrary to the facility's linen handling process.
Infection control practices were not followed in a shared shower room when a commode seat had visible brown substance on it, and staff described a process where nursing cleaned the seat before housekeeping sanitized the commode. Staff also failed to follow EBP during wound care for a resident with a right hip wound who was under hospice care and moderately impaired for daily decisions; although a room sign indicated gloves and gowns were required for wound care, an LPN and RN provided the treatment without gowns.
Infection control practices were not followed during medication administration and resident care. An RN handled medications with bare hands during a med pass, including opening a capsule and pouring the contents into pudding. Linens and a wet washcloth were observed on the floor in resident rooms, an incentive spirometer was found under a resident's bed, and a CPAP mask was left uncovered on a nightstand. The ADON stated that linens should not be left on the floor and respiratory equipment should be bagged when not in use.
The facility failed to complete the required water management risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread, and staff did not consistently follow contact precautions for a resident with MSSA bacteremia. The resident had ESRD on intermittent dialysis, was ordered to remain on contact precautions, and was observed with a contact sign and PPE cart outside the room, but no separate trash cans for PPE or linens were present and an LPN entered the room without PPE.
Staff failed to perform hand hygiene between resident contacts while passing lunch trays and assisting residents with eating. CNA4, CNA18, and the ADON touched residents during meal service without sanitizing hands between residents, and one CNA gave bites to two residents without hand hygiene in between. A CNA also handled dirty linen with a gloved hand in the hall and touched the gate and soiled utility door code before removing gloves and cleaning hands.
An LPN with long artificial nails repeatedly failed to follow hand hygiene and infection control practices during a med pass involving multiple residents. The LPN handled oral meds directly in the bare hand, including scooping pills from multi‑dose bottles with a fingernail and transferring pills from blister packs into the palm before placing them in cups, and picked up a pill from the top of the med cart with a bare hand. After performing a fingerstick blood glucose check with a glucometer and administering meds, the LPN removed gloves, placed the glucometer on and then into the med cart without disinfecting it, and documented on the computer without performing hand hygiene. The LPN continued to administer meds, prepare MiraLAX, access the treatment cart, and handle wound care supplies while moving between resident rooms, the med cart, and the nurses’ station, all without hand hygiene, contrary to facility policies on handwashing, ABHR use, and fingernail standards.
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