Springbrook Center: Infection Control Failures - ME

The nurse at Springbrook Center was observed on September 23 providing care to a resident colonized with MRSA and Pseudomonas aeruginosa without wearing the gown and face protection mandated by the facility's own infection control policies. When asked directly if she should wear protective equipment during the procedure, the LPN said she "does not wear a gown and or face/eye protection, only gloves when she performs the trach care."

The same nurse later violated hand hygiene protocols during wound care for another high-risk resident. She used the same gloved hands to remove a soiled dressing and apply a new one without washing between steps, acknowledging to the inspector that "she should have washed her hands and applied new gloves before cleansing and applying the new dressing."

Federal inspectors found the facility failed to implement infection prevention protocols for multidrug-resistant organisms affecting two residents on the Wayside Gardens unit. The violations put all 21 residents on the unit at potential risk for infection transmission.

Both residents required enhanced barrier precautions under facility policy. Stop signs posted outside their rooms specifically instructed staff to wear gowns and gloves for wound care and noted that face protection "may also be needed if performing activity with risk of splash or spray." Carts stocked with protective equipment sat directly outside both rooms.

The facility's tracheostomy care procedure explicitly requires nurses to "put on PPE including eye protection and face mask, as indicated." For wound dressings, policy mandates staff "apply personal protective equipment as indicated" and perform hand hygiene between removing old dressings and applying new ones.

Resident #48 carried special instructions in their medical record noting colonization with MRSA and Pseudomonas aeruginosa, requiring enhanced barrier precautions. During the observed tracheostomy care, the LPN performed hand hygiene and applied sterile gloves but skipped the required gown and face protection. She suctioned the tracheostomy cannula, removed the soiled split sponge, cleaned around the stoma, replaced the inner cannula and applied a new split sponge without additional protective equipment.

The procedure involved direct contact with secretions from a patient colonized with organisms resistant to multiple antibiotics. MRSA infections can be life-threatening and difficult to treat due to resistance to methicillin and other common antibiotics.

Twenty minutes later, the same nurse provided wound care to Resident #79, whose medical record carried special instructions for "MDRO risk due to wounds" requiring enhanced barrier precautions. The LPN prepared supplies by spraying gauze with wound wash, then applied clean gloves to remove the soiled dressing and cleanse the wound.

Without changing gloves or performing hand hygiene, she continued using the same gloved hands to spray the wound bed with wound wash, pat it dry with gauze, and apply both primary and secondary dressings. The cross-contamination violated basic infection control principles designed to prevent spreading resistant organisms.

The facility's wound dressing policy requires staff to "discard soiled dressing and gloves, perform hand hygiene, apply gloves" before proceeding with wound cleansing and new dressing application. The observed practice bypassed these critical safety steps.

Enhanced barrier precautions apply to patients with targeted multidrug-resistant organisms and those with chronic wounds or medical devices like tracheostomies, regardless of colonization status. The policy requires gowns and gloves during "high contact patient care activities" including device care, tracheostomy procedures, and wound care for any skin opening requiring a dressing.

Both residents met criteria requiring the enhanced precautions. Resident #48 had both MDRO colonization and a tracheostomy. Resident #79 had chronic wounds placing them in the high-risk category even without confirmed MDRO colonization.

The Director of Nursing confirmed the violations during an interview on September 23. The facility's Infection Preventionist later verified that nurses receive education on enhanced barrier precautions and should wear gowns, gloves and "whole face covering and/or mask/goggles when performing tracheostomy or wound care due to risk of splashes or sprays."

The gap between policy and practice suggests systemic failures in infection control implementation. Despite clear written procedures, available equipment, and posted reminders, staff performed high-risk procedures without following basic safety protocols designed to protect both patients and healthcare workers.

Multidrug-resistant organisms pose particular dangers in nursing home settings where residents often have compromised immune systems and multiple medical conditions. MRSA can cause serious skin and soft tissue infections, pneumonia, and bloodstream infections. Pseudomonas aeruginosa frequently infects wounds and can cause pneumonia in vulnerable patients.

The violations occurred during routine care activities that happen daily in long-term care facilities. Tracheostomy care typically requires multiple daily interventions, while wound care schedules vary based on healing progress and physician orders.

Federal inspectors documented the infection control failures as having "minimal harm or potential for actual harm" but noted the violations affected "some" residents. The classification indicates inspectors found evidence of regulatory non-compliance without documenting actual resident injury.

The Administrator and Director of Nursing confirmed the findings during a September 23 interview. The facility now faces federal oversight to ensure implementation of proper infection prevention protocols for residents requiring enhanced barrier precautions.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Springbrook Center from 2024-07-19 including all violations, facility responses, and corrective action plans.

Additional Resources

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