Inadequate Infection Control Measures in LTC Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during a recertification survey. Resident #45, who tested positive for Covid-19, was not placed on enhanced droplet/contact precautions, and staff were observed within six feet of the resident without wearing appropriate personal protective equipment (PPE). Additionally, Resident #100, who also tested positive for Covid-19, was placed on contact precautions instead of the required airborne precautions, and staff were observed handling the resident's environment without proper PPE. Resident #79, admitted with an open area on their leg and later developing a pressure ulcer, was not placed on enhanced barrier precautions. Staff were observed changing the dressing on the resident's heel ulcer without wearing a gown. Similarly, Resident #104, admitted with an unstageable pressure ulcer, was not placed on enhanced barrier precautions. Resident #16, who was on enhanced barrier precautions due to a multi-drug-resistant organism, was assisted by staff who only wore gloves during high-contact personal care, contrary to the requirement to wear gowns and gloves. The facility's Infection Prevention and Control Program policies and procedures were not reviewed annually as required. The Registered Nurse Educator/Infection Preventionist acknowledged the lapses in precaution signage and PPE usage, and the Director of Nursing confirmed that residents with certain conditions should have been on enhanced barrier precautions. The facility's failure to adhere to infection control protocols and ensure staff compliance with PPE requirements contributed to the deficiencies observed during the survey.
Plan Of Correction
Plan of Correction: Approved March 19, 2025 F880 Corrective Action - To assure the facility establishes and maintains an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 1. On 2/27/25 Resident #45 was placed on enhanced droplet/contact precautions for Covid-19 and the proper precaution sign was posted. CNA #4 was educated on proper PPE for enhanced droplet/contact precautions including wearing a mask/face shield. On 2/27/25 Resident #79 was placed on enhanced barrier precautions and the proper precaution sign was posted. The RN Educator and the Nurse practitioner were educated on proper PPE/gown use. On 2/27/25 Resident #100 was placed on enhanced droplet/contact precautions and CNA #3 was educated on proper PPE for precautions. Resident #104 was placed on enhanced barrier precautions. Additionally, the facility will ensure that Infection Prevention and Control Program policies are reviewed annually. Resident #16’s care plan was reviewed to assure the resident's enhanced barrier precautions remained appropriate and the proper precaution sign was posted. CNA #1 and #2 were educated on proper PPE precautions. 2. All residents who have respiratory symptoms and are being tested for COVID-19 have the potential to be affected by this deficient practice. A list of residents who have respiratory symptoms and are being tested for COVID-19 will be audited to ensure they are on enhanced droplet/contact precautions per policy, their care plan will be updated as necessary, and that appropriate PPE is utilized by staff. All residents who have a wound with an expected healing time of greater than 4 weeks as per policy have the potential to be affected by this deficient practice. A list of residents with wounds will be generated and audited to determine if enhanced barrier precautions are necessary and their care plan will be updated as necessary, and that appropriate PPE is utilized by staff. 3. The facility policies for its Infection Control Program including: Infection Prevention and Control - General Statement, Policy on Use of Criteria for Infection Identification, Antibiotic Stewardship Program, Policy on Influenza Immunization (Seasonal/H1N1), Pneumococcal Vaccination Program - Residents, Policy on Surveillance, PPE Donning and Doffing, Enhanced Barrier Precautions and Coronavirus Policies will be reviewed and updated (if necessary), as well as annually. All facility staff will be educated on PPE Donning and Doffing. And all licensed nursing staff (RN/LPNs) will be educated on all our Infection Control Program policies listed above. The Director of Nursing/Designee will oversee the completion of these in-services. 4. To prevent future deficient practice, the Director of Nursing/Designee will perform 10 audits per month for 3 months, and then as needed based on findings. Audits will verify that residents on precautions (EBP, contact/droplet/airborne) have appropriate precaution signs on doors and that appropriate PPE is worn by staff during direct care. The Director of Nursing will monitor this process and review the results monthly at QAPI meetings. If continued improvement is needed, the Committee may make further recommendations. The Director of Nursing will assume overall responsibility for correction of F 880.