Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. For Resident 19, who had a Stage 4 pressure ulcer and was on Enhanced Barrier Precautions (EBP), a Licensed Practical Nurse (LPN) did not apply a gown during wound care, contrary to the facility's policy and the resident's care plan. The LPN incorrectly assumed that EBP was no longer necessary due to the discontinuation of the resident's feeding tube, which was not aligned with the guidelines for residents with wounds. Resident 62, who required extensive assistance and had skin integrity issues, was also subject to improper infection control practices. During wound care, the LPN failed to remove gloves and perform hand hygiene after completing the wound care and before touching the resident's oxygen equipment and bedding. This action was against the facility's policy, which mandates hand hygiene between tasks to prevent cross-contamination. Additionally, during medication administration for Residents 45 and 47, another LPN handled medications with bare hands and did not perform hand hygiene between residents. This practice violated the facility's policy requiring gloves when handling medications and hand hygiene between residents. Furthermore, Resident 76, who had a dialysis catheter, did not have appropriate signage for EBP until a day after it was ordered, indicating a lapse in implementing necessary infection control measures.
Plan Of Correction
1. Residents 19, 45, 47, 62 and 76 had no ill effects. Resident 76's enhanced barrier precautions were added. 2. Review of residents with central venous catheters were reviewed to ensure enhanced barrier precautions were reviewed and ensured to have enhanced barrier precautions were in place. Licensed Staff educated on following enhanced barrier precautions, hand washing following a treatment and not touching medications with bare hands. 3. Assistant Director of Nursing or designee will audit residents with central venous catheters have enhanced barrier precautions in place weekly times four weeks and monthly times two months. Registered Nurse Assessment Coordinator or designee will audit that enhanced barrier precautions during wound care and hand washing following wound care is being completed weekly times four weeks and monthly times two months. Admissions Director or designee will audit to ensure medications are not being touched with bare hands weekly times four weeks and monthly times two weeks. 4. The Quality Assurance Performance Improvement committee will review previous survey/complaint deficiencies to ensure compliance.