Staff failed to follow infection control practices during medication administration and did not maintain organized infection surveillance documentation. An LPN was observed handling an oral medication with bare hands before administering it to a resident, contrary to the DON’s stated expectation that pills be dispensed directly into medication cups without hand contact and that any contaminated dose be discarded. Additionally, the DON, who also served as the Infection Preventionist, reported that several residents had influenza during a past holiday season but had no list of affected residents or rooms, and the requested infection control surveillance logs and a formal tracking system were not available.
A facility failed to maintain infection prevention and control practices during resident care and dining. A resident with a central venous catheter had no EBP signage observed, staff gave conflicting information about whether EBP was required, hand hygiene was not performed between glove changes during wound care for a resident with buttock wounds, and a CNA touched a chair and then the resident's food with the same gloves during meal assistance.
The facility failed to maintain infection control practices for two residents. One resident with a Foley catheter had the catheter bag observed on the floor instead of kept below the bladder and off the floor in a privacy bag, despite staff stating it should not be placed on the floor. A second resident receiving wound care had dressing removal followed by continued wound care without the LPN doffing dirty gloves, performing hand hygiene, and donning clean gloves before cleaning the wounds.
The facility failed to maintain an infection prevention and control program. Staff handled a resident’s feeding tube without the full EBP described in the report, including not using gowns and leaving the tube uncapped when not in use. Another resident who was ordered EBP for a catheter and wounds had no EBP sign or supplies observed in or outside the room. During lunch service, a CNA touched a resident’s food bare handed and also handled another resident’s sandwich bare handed.
Staff failed to follow Enhanced Barrier Precautions (EBP) for a resident with an NG feeding tube and significant comorbidities, including cerebral palsy, dysphagia, and severe protein-calorie malnutrition. Surveyors observed an RN reconnect an uncapped feeding tube that had been touching a metal IV pole while wearing only gloves and no gown, despite an EBP sign on the door. On another occasion, a speech therapist provided multiple PO trials and repositioned the resident while wearing gloves but no gown. In interviews, the RN, CNA Coordinator, and DON all confirmed that residents with feeding tubes require PPE, including gowns and gloves, when handling tube feedings or feeding the resident under EBP.
Infection prevention and control was not maintained when EBP was inconsistently implemented for residents with PICC lines, an NG tube, a chronic wound, and an indwelling catheter. Staff were observed using gloves without gowns, one RN exited a room without hand hygiene after handling a PICC line, and there was no EBP signage for some residents. Clean linens were also observed on the laundry room floor.
A resident with MRSA, wounds, and a PICC line was not placed on appropriate contact precautions, as required by facility policy and CDC guidance. Staff were unclear about the differences between Enhanced Barrier Precautions and Contact Precautions, and the resident participated in therapy sessions outside their room without proper signage or PPE protocols in place, resulting in a breakdown of the infection prevention and control program.
The facility did not consistently disinfect glucose monitors between resident uses and failed to implement Enhanced Barrier Precautions for a resident with a PICC line, despite physician orders and care plan directives. Staff demonstrated inconsistent understanding and application of infection control protocols, and necessary PPE and signage were not present for residents requiring EBP.
Staff failed to consistently follow Enhanced Barrier Precautions and infection control protocols, including not donning required PPE, not performing hand hygiene during dressing changes, and improper cleaning techniques for central line care. PPE signage was inconsistently marked, and staff demonstrated confusion about EBP requirements, resulting in care for residents with wounds, central lines, and indwelling devices being provided without appropriate infection prevention measures.
A CNA did not perform hand hygiene or use required personal protective equipment when caring for a resident under enhanced barrier precautions for a wound. The CNA exited the room, handled potentially contaminated items, and entered another resident's room without sanitizing hands, contrary to facility policy. The DON confirmed that the resident still required these precautions.
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