Inadequate Infection Control Practices for Residents on Enhanced Precautions
Penalty
Summary
The facility failed to maintain proper infection control practices for two residents on enhanced precautions. Resident #1, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was observed being transferred by a Certified Nursing Assistant (CNA) and a Licensed Practical Nurse (LPN) without wearing gowns, despite the resident having a G-Tube, Foley catheter, and a stage IV wound. Additionally, video reviews showed multiple instances where CNAs and Resident Assistants provided care to Resident #1, such as bed baths and catheter management, without wearing gowns, which was against the facility's infection prevention policy. Similarly, Resident #6, who was cognitively intact and had a urinary catheter, was also on enhanced barrier precautions. However, during a transfer from bed to chair, none of the staff members involved wore gowns, despite the presence of a precaution sign on the resident's door. These actions were in direct violation of the facility's infection control policy, which mandates the use of gowns and gloves during high-contact resident care activities to prevent the transmission of multi-drug resistant organisms.
Plan Of Correction
Plan of Correction: Approved December 23, 2024 The three staff members have been terminated based on the findings of the investigation. Licensed Practical Nurse #9, Certified Nursing Assistant #6, #7, #8 and Resident Assistant #15 were re-educated on Enhanced Barrier Precautions PPE requirements. The DON or designee will audit all residents who are currently EBP to ensure staff are following policy and procedure. Education has been provided to all facility staff on enhanced barrier precautions. The facility policy will change this education from upon hire and annually, to upon hire and quarterly going forward. The Director of Nursing or Designee will audit all residents who are currently EBP to ensure staff are following policy and procedure weekly for 3 months. Any noncompliance will be immediately corrected and reported to QAPI. The Director of Nursing or designee will audit staff education to ensure compliance weekly for 3 months then monthly thereafter. Any findings will be reported to QAPI. Responsibility: Director of Nursing and Infection Control Preventionist (ICP) or Designee