Infection Control Policy Breach
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies, specifically the Enhanced Barrier Precautions, for two residents. Resident 27, who had a Stage 3 pressure sore on his lower back, was examined by a physician who did not wear a protective gown as required by the facility's policy during high-risk activities. Similarly, Resident 35, who had a history of stroke and received nutrition through a feeding tube, was attended to by an LPN who flushed the feeding tube without wearing a gown, contrary to the facility's guidelines. These actions were observed during specific encounters and were not in compliance with the established infection control procedures.
Plan Of Correction
Unable to retroactively correct this alleged deficient practice. Resident 27 & 35 had no negative outcome related to alleged deficient practice. MD1 & LPN1 were provided education on EBP. An audit of current residents will be completed to ensure EBP is being followed by staff. DON/designee will educate direct care staff on the components of this regulation with emphasis on Enhance Barrier Precautions. DON/designee will conduct random audits of staff performing care in EBP rooms to ensure proper PPE is worn. Audit will be conducted 2x a week x 4 weeks then, 1x a week x 4 weeks then, 2x a month x 2 months then, 1x a month x 2 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings during QAPI.