Inadequate Infection Control Practices in Resident Care
Penalty
Summary
The facility failed to adhere to appropriate infection prevention and control practices, specifically in the use of hand hygiene and personal protective equipment (PPE) during care for two residents. Resident #65, who had a history of atherosclerosis with gangrene, diabetes, and an unhealed Stage 3 pressure ulcer, was observed receiving incontinence care without the use of a gown by Staff A, a CNA. Staff A did not change gloves or perform hand hygiene during the care process, despite the presence of feces, and there was no Enhanced Barrier Precautions (EBP) signage or PPE available in the resident's room. Resident #61, who required daily wound care for open areas on the right heel and leg, also did not have EBP signage or PPE set up at the room. During a dressing change, Staff E, a Unit Manager, did not wear a protective gown. The facility's Director of Nursing (DON) admitted to misunderstanding the guidelines for EBP, which led to the removal of EBP signs from residents' rooms and a lack of proper precautions during care. The deficiencies were identified through observations and interviews, revealing a lack of compliance with the facility's own policy on EBP. The DON acknowledged the oversight and misunderstanding of the EBP guidelines, which contributed to the improper infection control practices observed during the care of Residents #65 and #61.
Plan Of Correction
F880- Tag Control What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident# 65 was observed for sign or symptoms of none discovered. DON was educated by Corporate Chief Clinical Director on Enhanced Barrier Precautions (EBP) during survey and an action plan presented to survey team. CNA who demonstrated deficient washing and gloving practice received a 1:1 in-service on by DON. All staff educated on EBP and the need for wearing gloves and gowns while providing care by. How will you identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken. A review of all residents was done to identify those who meet criteria for EBP. Signage was posted on the doors of all residents with EBP status and supplies placed in containers in hallway or on residents' doors on. Goal of 95-100% of all staff are reeducated by on handwashing and glove donning/doffing and changing is compliant with control procedures for. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. The ongoing EBP in-service will occur weekly for new employees. Bins with PPE have been placed in hallways for easy access by staff effective. How the corrective action(s) will be monitored to ensure the deficient practice will not recur. What quality assurance program will be put into place. The DON/designee will conduct quality review observations of ADL care for 5 residents dependent on ADL care weekly x 4 weeks, bi-weekly for every 2 weeks x 2 months then PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 3 months or until substantial compliance is achieved. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.