WORCESTER, MA - A February 2025 state inspection at Notre Dame Long Term Care Center revealed significant failures in infection control protocols and adaptive equipment provision that put vulnerable residents at risk for complications and reduced independence.
Critical Infection Control Failures Documented
The inspection found serious breaches in infection prevention standards affecting two residents, with staff failing to follow established Enhanced Barrier Precautions and proper hand hygiene during high-risk medical procedures.
For Resident #103, who required Enhanced Barrier Precautions due to an indwelling urinary catheter, hospice staff provided direct care without wearing required protective gowns. The resident, admitted in September 2024 with diagnoses including diabetes and kidney disorders, had been placed on hospice care in January 2025. Despite clear signage indicating Enhanced Barrier Precautions were required, a hospice staff member was observed adjusting the resident's catheter drainage bag and tubing while wearing only gloves, not the mandated gown and glove combination.
"She had never worn a gown to care for the Resident," the hospice staff member told investigators, admitting she hadn't noticed the Enhanced Barrier Precaution sign despite caring for the resident twice weekly for approximately two months.
The facility's own Enhanced Barrier Precautions policy, revised in August 2022, clearly states that protective gowns and gloves must be used during high-contact care activities involving medical devices like urinary catheters. These precautions are specifically designed to reduce transmission of multi-drug resistant organisms that can cause serious infections in vulnerable nursing home populations.
Severe Hand Hygiene Violations During Wound Care
Even more concerning were the multiple hand hygiene failures observed during wound care for Resident #84, who had an unstageable pressure ulcer on the coccyx and a history of MRSA infection. The inspection documented a shocking pattern of contamination risks during a single wound care procedure.
Investigators observed the attending nurse repeatedly changing gloves without washing or sanitizing hands between glove changes - a fundamental violation of infection control standards. The nurse also used unsterilized scissors from her pocket to cut calcium alginate dressing material, handled a pen from her pocket during the procedure, and moved between different areas of the room without proper hand hygiene.
"She should have cleaned or sanitized her hands between removing gloves, but she did not," the nurse acknowledged during questioning.
This pattern of poor infection control is particularly dangerous for residents with wounds and MRSA infections. MRSA (Methicillin-resistant Staphylococcus aureus) is a type of bacteria resistant to many antibiotics and can cause life-threatening infections if spread to other residents or if the existing infection worsens.
Medical Significance of Infection Control Violations
Proper infection control in nursing homes is critical because residents typically have compromised immune systems and multiple chronic conditions that make them highly susceptible to healthcare-associated infections. Enhanced Barrier Precautions represent an evidence-based intervention specifically developed to prevent transmission of dangerous multi-drug resistant organisms.
When staff fail to follow these protocols, they create pathways for bacteria to spread from contaminated surfaces, equipment, or their own hands and clothing to vulnerable residents. For residents with indwelling catheters, this can lead to urinary tract infections that may progress to sepsis - a potentially fatal condition.
The hand hygiene violations during wound care are equally serious. Each time the nurse changed gloves without hand hygiene, she potentially transferred bacteria from contaminated surfaces to the sterile wound environment. Using unsterilized equipment like pocket scissors in wound care directly introduces environmental bacteria to an open wound, increasing infection risk substantially.
According to established medical protocols, healthcare workers should perform hand hygiene immediately after glove removal, before donning new gloves, and after contact with potentially contaminated surfaces. All equipment used in wound care should be sterile or properly disinfected.
Adaptive Equipment Failures Compromise Independence
The inspection also revealed failures in providing essential adaptive eating equipment that compromises residents' ability to maintain independence during meals. Resident #75, who has dementia and generalized muscle weakness, was repeatedly served meals without the required built-up handle utensils despite clear documentation in care plans and diet orders.
Investigators observed the resident struggling to eat scrambled eggs with standard silverware, resulting in food spilling onto the resident's chest. On a subsequent observation, the resident was unable to use standard utensils effectively and resorted to eating with his hands.
"If the Resident did not get those utensils at meals it was a mistake because the diet slip said to provide them," a certified nursing aide explained, noting that adaptive equipment requirements were highlighted in yellow on diet slips.
The resident's occupational therapy discharge summary specifically indicated that adaptive utensils were necessary to "preserve current level of function" - meaning that without proper equipment, the resident's eating abilities would likely deteriorate more rapidly.
Built-up handle utensils are specifically designed for individuals with limited hand strength or dexterity. They allow residents to maintain independence during meals, which is crucial for both physical nutrition and psychological well-being. When residents cannot feed themselves effectively, they may eat less, leading to malnutrition and weight loss.
Additional Issues Identified
The inspection documented several other concerning patterns, including inadequate staff training on meal tray delivery procedures and insufficient oversight of adaptive equipment provision. Staff members acknowledged they were supposed to check diet slips for special requirements before serving meals, but the system clearly failed multiple times for the same resident.
The facility's policies appeared comprehensive and appropriate, but implementation and staff compliance were clearly inadequate. Both nursing staff and certified nursing aides demonstrated awareness of requirements but failed to consistently follow established procedures.
The violations represent systemic failures in quality assurance and staff supervision rather than isolated incidents, suggesting broader issues with the facility's oversight mechanisms and staff accountability systems.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Notre Dame Long Term Care Center from 2025-02-12 including all violations, facility responses, and corrective action plans.
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