Infection Control and Reporting Failures
Penalty
Summary
The facility failed to report and manage infection control for COVID-19 and respiratory illnesses for two residents. Resident R369, who had a history of opioid dependence, respiratory conditions, and a hip fracture, was admitted to the facility and later complained of shortness of breath and a productive cough. Despite these symptoms, the resident was not tested for respiratory illnesses until after being sent to the hospital, where they tested positive for COVID-19. The facility did not report this positive COVID-19 diagnosis to the local state field office. Similarly, Resident R80, who had diagnoses of anxiety, depression, and muscle weakness, exhibited symptoms of a cough and congestion but was not tested for respiratory illnesses during the facility's COVID outbreak. The resident's condition worsened, leading to a hospital transfer due to shortness of breath and low oxygen saturation levels. The facility's infection preventionist confirmed that the facility failed to conduct timely testing and did not develop a line listing report for the COVID outbreak. Additionally, during a medication pass, an LPN failed to perform proper hand hygiene between administering medications to different residents, leading to potential cross-contamination. The LPN confirmed the failure to wash hands after removing gloves and before donning a new pair, which is a breach of infection control procedures. These deficiencies highlight lapses in the facility's infection prevention and control program, particularly in managing and reporting COVID-19 cases and ensuring proper hygiene practices during medication administration.
Plan Of Correction
Unable to rectify COVID testing for residents R80 and R369. LPN/IP Employee E20 will be re-educated on Infection Preventionist Role and job description and the facility policy for testing residents for COVID-19. Facility will provide training to Employee E20 from sister facility Infection Preventionist. Education with Licensed nursing staff on proper handwashing during medication pass, and the facility policy for testing residents for COVID-19 will be conducted by DON/Designee. Audits will be performed weekly x 4 weeks by the DON/Designee to ensure compliance with testing residents for COVID-19. The DON/Designee will conduct handwashing Audits during random medication passes 3x a week times 2 week, 2x a week times x2 weeks, 1x a week times 2 weeks until compliance is met. Findings from the audits will be presented at QAPI quarterly meetings for review and recommendations.