Inadequate Infection Control and PPE Use
Penalty
Summary
The facility failed to maintain an effective Infection Control Program, as evidenced by the improper use of Personal Protective Equipment (PPE) by staff when providing care to residents on Enhanced Barrier Precautions. Resident #34, who had multiple wounds and was at risk for infection, was observed receiving wound care from an LPN who wore gloves but no gown, despite the requirement for full PPE. Similarly, Resident #45, who had a pressure ulcer and an indwelling urinary catheter, was not properly managed under Enhanced Barrier Precautions, as staff entered the room and provided care without wearing gowns, even though the Director of Nursing acknowledged the need for full PPE. Resident #99, who had a feeding tube and a colonized multi drug-resistant organism, was also not managed according to Enhanced Barrier Precautions. An LPN entered the resident's room without performing hand hygiene and wore gloves but no gown while administering care. There was no signage indicating Enhanced Barrier Precautions, and PPE was not readily accessible outside the resident's room. The Director of Nursing admitted that the resident should have been on Enhanced Barrier Precautions, and there was confusion among staff about responsibilities for signage and PPE placement. Additionally, the facility did not enforce its policy regarding influenza vaccination declination. Staff who declined the influenza vaccine were observed not wearing face masks in resident care areas during the influenza season. Despite being aware of the policy, staff members, including a CNA and an LPN, were found without masks, indicating a lack of adherence to infection control measures. The Regional Director of Clinical Services confirmed that staff are trained on these policies, but the implementation was not consistent, as evidenced by the observations during the survey.
Plan Of Correction
Plan of Correction: Approved February 7, 2025 1. Resident #34, #45, and #99 were assessed for any adverse effects without the usage of PPE with no visible signs of infection. LPNs will be re-educated on Enhanced Barrier Precautions. DON will be re-educated on Enhanced Barrier Precautions. RNs will be re-educated on Enhanced Barrier Precautions. CNAs will be re-educated on Enhanced Barrier Precautions. All staff will be re-educated on influenza season and proper mask wearing. 2. An infection control audit will be conducted. This audit will ensure that EBP are implemented for indicated residents. All residents who meet the criteria were placed on EBP. 3. The facility educator/designee will educate facility staff on infection control, proper face mask wearing, and EBP. The following policies were reviewed without changes: Enhanced Barrier Precautions and Influenza Vaccine. The facility infection preventionist/designee will conduct frequent infection control rounding, including during wound rounds, and any identified opportunities will be addressed upon discovery. The infection preventionist, director of nursing, and other facility leadership will conduct rounds throughout the facility to ensure that staff members are exercising appropriate use of personal protective equipment. Ad hoc education will be provided to persons who are not correctly adhering to infection prevention/control practices. Licensed Nurses (staff/agency) will be reeducated on infection control practices during wound care (EBP). Employees (staff/agency) will be reeducated on infection control practices. Employees (staff/agency) will be reeducated upon hire, annually, and as necessary. 4. The Infection Preventionist/designee will audit the infection control practices during 5 wound treatments weekly x 12 weeks or until substantial compliance is achieved. The Infection Preventionist/designee will conduct infection control rounds for proper mask-wearing on 20 employees weekly x 12 weeks or until substantial compliance is achieved. The DON or designee will report the findings to the Quality Assurance Performance Improvement Committee. Responsible Party: Infection Preventionist/DON