Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to infection control guidelines as outlined by the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC), resulting in deficiencies in the implementation of Enhanced Barrier Precautions (EBP) for several residents. The report highlights that the facility did not implement EBP for residents with indwelling medical devices or chronic wounds until November 27, 2024, despite having residents with conditions that warranted such precautions. This oversight affected multiple residents, including those with indwelling catheters, pressure ulcers, and infections with multidrug-resistant organisms (MDROs). Observations and staff interviews revealed specific instances of non-compliance with infection control practices. For example, a Licensed Practical Nurse (LPN) failed to perform hand hygiene between glove changes during wound care for a resident with pressure ulcers, which is a critical step in preventing cross-contamination. Additionally, there was a lack of proper signage and personal protective equipment (PPE) availability for residents on transmission-based precautions, as evidenced by the case of a resident with a methicillin-resistant Staphylococcus aureus (MRSA) infection. The facility's infection preventionist and Director of Nursing confirmed the lapses in implementing EBP and maintaining proper infection control measures. These deficiencies were identified through a review of clinical records, facility policies, and direct observations, indicating a systemic issue in the facility's infection prevention and control program. The report underscores the need for adherence to established guidelines to prevent the spread of infections and protect both residents and staff.
Plan Of Correction
1. Residents 7, 8, 11, 12, 34, 63, 70, and 80 suffered no ill effects. EBP for residents 7, 11, 12, 63, 70, and 80 was implemented on 11.27.2024. Signage for Enhanced Barrier Precautions was replaced for resident 34. 2. Baseline audit done on all residents needing Enhanced Barrier Precautions to ensure all needed signage is posted. 3. Education completed with all nursing staff on hand hygiene to include demonstration and with housekeeping and nursing to ensure EBP signage stays in place at all times. Nursing staff reeducated on residents that require the need for enhanced barrier precautions. 4. Audits will be completed 2 x week for 2 weeks and monthly for 2 months to ensure all residents' doors that require EBP signage is up and current. Audit on staff hand hygiene will be done 5 x a week for 2 weeks. 5. Date of compliance 3/5/2025.