Failure to Implement Infection Control and Proper Storage Procedures
Penalty
Summary
The facility failed to implement enhanced barrier infection control procedures for three residents and did not properly store resident hygiene and personal products in two shower rooms. For Residents 28, 33, and 56, there were no signs or postings indicating that they were on enhanced barrier precautions, despite physician orders requiring such precautions due to conditions like MRSA in urine, a PEG tube, and an indwelling urinary catheter. Observations confirmed the absence of required signage, and staff interviews corroborated that the rooms should have been marked to indicate the need for gowns and gloves during high-contact care activities. Additionally, the facility did not ensure proper storage of resident hygiene products, as observed in the 3rd and 4th-floor shower rooms. Items such as incontinence briefs, a hairdryer, and sanitizing wipes were stored directly on the floor and in a bathtub, which poses a risk of contamination. Staff interviews confirmed that these items should not be stored in such a manner, and the Nursing Home Administrator acknowledged the facility's responsibility to implement proper infection control procedures, including the correct storage of personal products.
Plan Of Correction
1. Resident 28's contact precautions were discontinued and enhanced barrier precautions were implemented with indicators applied to the door. Resident 33 had appropriate enhanced barrier precaution indicators applied to the door. Resident 56 was discharged from the facility. The 3rd and 4th floor shower rooms were immediately cleaned. Items were removed from the floor and disposed of appropriately. Hair dryers were sanitized and stored appropriately. 2. The facility will complete an audit of current residents to ensure those requiring enhanced barrier precautions have appropriate indicators in place to ensure staff are aware. The facility will complete an audit of the shower rooms to ensure residents' personal products are stored properly. 3. The Infection Preventionist/designee will educate staff on the facility's enhanced barrier precautions policy and protocol. The Infection Preventionist/designee will educate clinical staff on proper storage of resident personal items and hygiene products. 4. The Infection Preventionist/designee will perform weekly audits of sampled residents with enhanced barrier precautions to ensure there are proper indicators in place. The Infection Preventionist/designee will perform weekly audits of shower rooms to ensure the proper storage of resident personal items and hygiene products. Results will be reviewed at the facility's monthly QAPI meeting. Audits will continue until substantial compliance is reached.