Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. The facility did not have a clear process to identify residents on Enhanced Barrier Precautions (EBP), as there was no signage outside resident rooms indicating the type of Personal Protective Equipment (PPE) required. This was observed in 8 out of 8 EBP rooms, where only an orange dot sticker was used, which staff and visitors did not understand. Additionally, PPE bins were not readily available outside these rooms, and staff education on EBP was inadequate, as evidenced by a CNA who was unaware of the meaning of the orange dot. The survey also revealed that the facility failed to ensure proper hand hygiene practices among staff and residents. During a lunch meal observation, staff did not offer hand hygiene to residents entering the dining room from the smoking area, nor was hand hygiene performed by staff between serving meals and assisting residents. An LPN was observed handling multiple meal trays and assisting residents without performing hand hygiene, despite passing several alcohol-based hand rub dispensers. The facility's hand hygiene policy was not adhered to, as staff did not wash their hands before and after assisting residents with meals. Additional deficiencies included improper use of gloves by an Occupational Therapist, who wore gloves while walking through non-clinical areas and interacting with multiple residents without removing them. The facility also failed to maintain sanitary conditions for ice storage, as observed with undated ice containers and non-self-draining ice scoops. Furthermore, a CNA was observed using a cell phone and then assisting a resident with feeding without performing hand hygiene. These actions were contrary to the facility's infection control policies and CDC guidelines, highlighting a lack of adherence to established protocols for preventing the spread of infection.
Plan Of Correction
Rose Mountain Care Center Facility ID 315384 Survey Date 12/12/24 **F880 SS-F Infection Control and Prevention** **ELEMENT ONE: CORRECTIVE ACTION** All staff were in-serviced on the process and identification of residents on Enhanced Barrier Precautions (EBP) on 12/3/2024. The family/residents on EBP were educated on the precautions and why they are utilized. All staff that pass out food trays were re-inserviced on 12/3/24-12/5/24 on hand hygiene for both residents and staff pre, post meal and when passing out trays. In addition, staff were re-inserviced on not leaving garbage including cup lids. The therapist who was observed in the hallway with gloves was inserviced immediately. The self-draining holders were installed in both units on 12/12/24. C.N.A. #2 was immediately re-in serviced and counseled on zero tolerance on phone use as per facility policy, and in employee handbook, educated upon hire, annually, and as evidenced by C.N.A. signature in employee handbook. In addition, C.N.A. #2 was re-in serviced on sitting level with resident while assisting with meals. **ELEMENT TWO: IDENTIFICATION OF AT RISK RESIDENTS:** All residents on EBP have the potential to be affected. All residents that require hand hygiene prior to meals and require assistance with meals can be affected. All residents who receive ice have the potential to be affected. All residents can be affected by staff personal cell phone use. **ELEMENT THREE: SYSTEMIC CHANGES:** All staff were inserviced on the process and identification of residents on Enhanced Barrier Precautions (EBP) on 12/3/2024. The family/residents were educated on the precautions and why they are utilized. Moving forward EBP will be discussed for residents/family to remind them of the precautions and their purpose at the residents care plan meeting. All staff that pass out food trays were re-inserviced on 12/3/24-12/5/24 on hand hygiene for both residents and staff pre, post meal and when passing out trays. In addition, staff were re-inserviced on not leaving garbage including cup lids. The U.S. FOIA (b) who was observed in the hallway with gloves was inserviced immediately. The self-draining holders were installed in both units on 12/12/24. C.N.A. #2 was immediately re-in serviced and counseled on zero tolerance on phone use as per facility policy, and in employee handbook, educated upon hire, annually, and as evidenced by C.N.A. signature in employee handbook. In addition, C.N.A. #2 was re-in serviced on sitting level with resident while assisting with meals. A visual audit of meal pass was completed daily x 5 days starting 12/5/2024 at various mealtimes to assess any staff members that may not be practicing proper hand washing with residents and when passing out trays, as well as when assisting residents to eat, staff is sitting. The Director of Nursing/Licensed Nursing Home Administrator completed daily facility rounds at different times to audit staff personal cell phone use. **ELEMENT FOUR: QUALITY ASSURANCE:** The infection preventionist will audit the residents on EBP monthly x 3 months and then quarterly. Food Service Director/Dietician/Designee will visually audit (and document) dining services at various times/meals to assess staff compliance with resident and staff hand hygiene, and staff are sitting when assisting resident with meals, daily x 5, weekly x 4 and monthly x 3. Needed corrections will be addressed as they are discovered. Findings to be reported to the QAPI team for review and action as necessary. **DATE OF COMPLIANCE: 12/25/24**