Inadequate Infection Control Practices Observed
Penalty
Summary
The facility failed to maintain and implement a comprehensive infection prevention and control program, as evidenced by multiple observations and interviews. Employee 3, a registered nurse, was observed administering medications to three residents on the A Hall nursing unit without following proper infection control techniques. The nurse used her bare hands to remove medications from the medication card and placed them in the residents' medication cups without performing hand hygiene or donning gloves. This occurred with the administration of Folic Acid to Resident 6, Tamsulosin to Resident 22, and Buspirone to Resident 32. The nurse also failed to wash her hands after administering the medications. The facility's infection control logs for August and September 2024 were incomplete, as confirmed by the Infection Preventionist (IP) and the Nursing Home Administrator (NHA). The IP, who started on September 23, 2024, verified that there was no current IP working in the facility prior to her hire, and the infection control tracking logs were not completed for those months. The NHA confirmed that the previous IP stopped working on August 30, 2024, and the new IP did not start until September 23, 2024, leading to a gap in infection control tracking. The facility's failure to demonstrate a comprehensive infection control program included a lack of a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, and visitors. This deficiency was confirmed through interviews with the Director of Nursing and the Infection Preventionist, highlighting the facility's inability to maintain a comprehensive program to monitor and prevent infections.
Plan Of Correction
The facility cannot retroactively correct the deficiency noted by the surveyor for residents 6, 22, and 32 on C-Hall. The facility understands that all residents have the potential to be affected by the deficiency as noted by the surveyor. Please see sections 3 for system changes. The Director of Nursing (DON) or designee will re-educate the Licensed Nursing Staff on medication administration and hand hygiene. The facility now has an Infection Preventionist (IP) as well as a backup who will be reviewing any new infections at the daily morning meeting and verify it is documented on the tracking log. The DON or designee will randomly audit medication pass, verify hand hygiene, and the tracking of infections weekly for 4 weeks and then monthly for 2 months to verify compliance. Audits will be submitted to the monthly QA committee meeting for review and any further recommendations for 3 months.