Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of staff not adhering to Enhanced Barrier Precautions for residents requiring such measures. Resident #39, who was on Enhanced Barrier Precautions due to a history of clostridium difficile, was observed receiving medication and parenteral feed administration through a gastrostomy tube without the administering nurse wearing a gown. Additionally, during incontinence care, staff failed to change gloves or wash hands before handling clean items, and soiled linens were placed directly on the floor without a barrier. Resident #96, who was dependent on staff for toileting hygiene, was observed receiving incontinence care without proper glove changes or hand hygiene being performed by the staff member. The staff member placed soiled linens directly on the bed and floor without a barrier, which was acknowledged as cross-contamination and an infection control issue. The staff member admitted to not following proper procedures, which was confirmed by interviews with other staff members who emphasized the importance of these practices to prevent the spread of germs. Residents #119 and #139, both requiring Enhanced Barrier Precautions due to indwelling medical devices, did not have appropriate signage indicating such precautions. Staff were observed performing high-contact activities, such as emptying a foley catheter and flushing a cholecystostomy tube, without wearing gowns. Interviews revealed that staff were either unaware of the precautions or did not notice the signage, indicating a lack of adherence to the facility's infection control policies.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Signage that indicated Enhanced Barrier Precautions were placed at doorways to resident #119 and #139 on 2/13/25. Resident #39 was assessed by medical provider; no signs/symptoms of adverse effects related to lack of PPE worn were present. Resident #96 was assessed by medical provider; no signs/symptoms of adverse effect related to lack of PPE worn were present. Certified Nurse Aide #5 was counselled and re-educated regarding infection control practices and expectations of hand hygiene and glove changing protocols in regards to providing incontinent care. Certified Nurse Aide #6 was counselled and re-educated regarding infection control practices and expectations of hand hygiene and glove changing protocols in regards to providing incontinent care as well as policy/procedure for soiled linen handling/transport. Nursing Supervisor Registered Nurse #5 was counselled and re-educated regarding infection control practices and expectations of proper PPE for Enhanced Barrier Precautions when handling medical equipment involving bodily fluids. All residents on precautions have the potential to be affected; UM’s rounded their units to identify potential concerns related to infection control practices. Concerns identified were addressed and corrected. The Infection Preventionist and unit managers will update and maintain a list of residents on EBP precautions for each unit. All Licensed Nurses and CNA’s will be educated by the RN Educator regarding infection control practices in regards to enhanced barrier precautions, PPE, hand-hygiene policy/procedures, and soiled linen handling/transport. This will include the prevention of transmission of communicable diseases, gowning during [MEDICATION NAME] administration through a percutaneous endoscopic gastrostomy tube along with the proper changing of gloved. Education will also include proper use of barriers and handling of soiled linen, urine drainage bags, cholecystostomy tubes and coordinating signage when applicable. All nurse management and IP nurse will be educated regarding policy/procedure for signage placement for those residents on precautions. Infection Preventionist/designee will audit 10 residents on EBP precautions weekly x 8 to ensure staff are adhering to policy/procedure regarding PPE use, glove changing, and hand hygiene for care rendered. Audit findings will be reviewed monthly by QAPI committee until the committee determines that compliance has been attained. Infection Preventionist/designee will audit all residents’ rooms on EBP precautions weekly x 8 weeks to ensure appropriate precaution signage and PPE isolation bins are present. Audit findings will be reviewed monthly by QAPI committee until the committee determines that compliance has been attained. Person Responsible: DON