The nurse, identified as RN C, entered Resident #2's room on enhanced barrier precautions and removed the colostomy without donning appropriate personal protective equipment. Enhanced barrier precaution signs were posted on the wall beside the resident's door, with a container of gowns, gloves, and other required safety gear positioned directly outside the room.
When questioned by inspectors, RN C acknowledged her violation of infection control protocols. She admitted that without wearing barrier precautions during the colostomy removal, "she could spread germs into the area." The nurse recognized that bacteria could transfer to her clothes and that "she may spread bacteria to other residents."
Despite having received training on enhanced barrier precautions, hand hygiene, and infection control, RN C failed to follow established safety measures. She could not recall the specific date of her training sessions.
The facility's Director of Nurses confirmed that all staff were expected to wear personal protective equipment when entering any resident room designated for enhanced barrier precautions. She stated that RN C "did not follow the facility's protocol for infection control" and confirmed there was potential for the nurse to spread bacteria from Resident #2 to other residents by failing to wear a gown.
The Director of Nurses emphasized that RN C had received proper training on infection control, enhanced barrier precautions, and hand hygiene. According to facility protocol, the nurse was required to wash or sanitize her hands whenever she touched anything considered contaminated. Both scissors and clothing were classified as contaminated items under facility guidelines.
Accel at College Station's written policies clearly outlined the requirements RN C violated. The facility's Personal Protective Equipment policy, dating to 2010, specified that gowns must be used to prevent the spread of infections, prevent soiling of clothing with infectious materials, and prevent splashing or spilling of blood or body fluids onto clothing or exposed skin.
The facility's hand hygiene policy, established in August 2015, designated hand hygiene as "the primary means to prevent the spread of infections." Staff were required to use alcohol-based hand rub containing at least 62 percent alcohol or soap and water before and after contact with residents, before performing any non-surgical invasive procedures, and before donning sterile gloves.
The inspection revealed a gap between the facility's written infection control protocols and actual practice. While safety equipment was readily available outside Resident #2's room and enhanced barrier precaution signs were clearly posted, the trained nurse chose not to use the required protective gear during an intimate care procedure involving bodily waste.
Colostomy care presents particular infection risks, as the procedure involves direct contact with fecal matter and requires manipulation of medical equipment attached to the resident's body. The failure to wear protective equipment during such procedures creates multiple pathways for bacterial transmission.
RN C's admission that bacteria could transfer to her clothing highlighted the broader risk to facility residents. Without proper protective equipment, contaminated clothing could carry bacteria from room to room as staff moved throughout the facility during their shifts.
The violation occurred despite the facility's emphasis on infection control training and the availability of all necessary safety equipment. The Director of Nurses confirmed that enhanced barrier precautions were standard protocol for certain residents, with clear expectations that all staff would comply with protective equipment requirements.
The inspection found that while policies existed on paper and training had been provided, implementation failed at the point of care. RN C's acknowledgment of the risks she created suggested awareness of proper procedures, making her decision to skip protective equipment particularly concerning.
Federal inspectors classified the violation as having minimal harm or potential for actual harm, affecting few residents. However, the incident exposed systemic vulnerabilities in infection control compliance that could impact the broader resident population.
The case illustrates how individual staff decisions can undermine facility-wide safety protocols, even when proper equipment and training are in place. RN C's choice to proceed without protective gear during colostomy care created unnecessary infection risks for vulnerable nursing home residents who depend on staff adherence to safety protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Accel At College Station from 2026-01-29 including all violations, facility responses, and corrective action plans.