Infection Control Deficiency at Forest Park Nursing and Rehabilitation
Penalty
Summary
Forest Park Nursing and Rehabilitation was found to be non-compliant with infection prevention and control requirements as outlined in 42 CFR Part 483.80. The facility failed to implement its infection control policies effectively, particularly during an outbreak of gastrointestinal symptoms among residents. The facility's policy on 'Isolation - Categories of Transmission-Based Precautions' was not adhered to, as staff did not follow the necessary precautions to prevent the spread of infection. Observations revealed that staff members, including Employees 1, 2, 3, 4, and 5, did not don personal protective equipment (PPE) such as gowns, gloves, or eye protection when entering rooms marked for 'Special Droplet/Contact Precautions.' Additionally, these employees failed to perform hand hygiene before and after entering the rooms. This lack of adherence to infection control protocols was observed across multiple units, including Laurel Lane, Evergreen, Stepping Stone, and Dementia units. The Director of Nursing confirmed that the facility had experienced an outbreak of gastrointestinal symptoms, prompting the implementation of contact precautions. However, staff interviews and observations indicated a widespread failure to comply with the facility's infection control policies. The Nursing Home Administrator acknowledged that it was the facility's expectation for staff to follow these protocols, yet the observed actions demonstrated a significant lapse in infection control practices.
Plan Of Correction
1. Director of Nursing/designee-initiated education for facility and agency staff on following isolation precautions including proper PPE usage. Director of Nursing/designee will conduct initial direct observation and audit to ensure staff can demonstrate proper PPE usage for the following affected residents: Resident # 17, 3. 1, 2, 4, 5. 2. Director of Nursing/designee will conduct a facility wide audit on current residents who are on isolation precautions to ensure proper isolation precautions are being followed including proper use of PPE as required by their specified isolation precautions via direct observation. 3. Director of Nursing/designee will review and update signage for droplet and contact precautions for isolation requirements as recommended by CDC guidelines. 4. Director of Nursing/Designee will audit and review residents needing isolation to ensure that staff are following transmission-based precautions including proper use of PPE required for resident specific isolation via direction observation. These audits will be conducted over all shifts weekly for four weeks and monthly for two months. Results of these audits will be reviewed by the Quality Assurance Performance Improvement committee for review and recommendations.