Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to adhere to infection prevention and control guidelines, particularly concerning Enhanced Barrier Precautions (EBP) for several residents. Resident #103 was observed without proper protective measures in place, as staff did not wear gowns while repositioning the resident, despite the presence of a drainage bag. The Infection Preventionist and Unit Manager acknowledged the oversight, attributing it to the resident's recent room change, which led to the delayed placement of a PPE cart. Resident #175's care also demonstrated lapses in following EBP protocols. Staff members, including a wound care nurse and a hospice aide, were observed providing care without wearing protective gowns, despite the resident's condition requiring such precautions. The staff admitted to being distracted or unaware of the need for gowns, indicating a lack of consistent adherence to the facility's infection control policies. Additionally, Resident #46 and Resident #39 were not provided with appropriate EBP measures. Staff failed to wear gowns during high-contact activities, such as transferring and wound care, and there was a lack of signage and PPE carts outside their rooms. These deficiencies highlight a systemic issue in the facility's implementation of infection control practices, as staff members were either unaware or neglectful of the necessary precautions for residents with specific medical needs.
Plan Of Correction
Corrective action completion date: F880 CONTROL PREVENTION& 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of Resident #103. The resident had risk for related to the and interventions did not include Enhanced Barrier Precautions. Nursing staff will be in-serviced on control and protocols for setting up Enhanced Barrier Precautions. 2) In the allegation of Resident #175, The Staff left the door open, privacy curtain halfway open and were not wearing proper PPE while doing care on a resident that had Enhanced Barrier Protection. Nursing staff will be in-serviced on dignity, closing door and pulling privacy curtain during care. Nursing staff will be in-serviced on wearing proper PPE while doing care for residents on Enhanced Barrier Protection. 3) In the allegation of Resident #46, the resident did not have an Enhanced Barrier Protection or care plan. There was no Enhanced Barrier Protection signage on the door and no PPE cart. Staff while transferring resident was not using proper PPE. Staff not wearing proper PPE while caring for resident. Nursing staff will be in-serviced about initiating proper care plans for residents who need care and Enhanced Barrier protection. Nursing staff will be in-serviced on wearing proper PPE while doing care for residents on Enhanced Barrier Protection. 4) In the allegation of Resident #276, during the staff did not do proper hygiene in between glove changes. Staff will be in-serviced to proper hygiene between glove changes. 5) In the allegation of Resident #278, during the staff did not do proper hygiene in between glove changes. Staff will be in-serviced to proper hygiene between glove changes. 6) In the allegation of Resident #39, during care, Care Staff was not wearing gowns, there was no Enhanced Barrier Precautions signage on the door no isolation cart. Nursing staff will be in-serviced on control and protocols for setting up Enhanced Barrier Precautions. Nursing staff will be in-serviced on wearing proper PPE while doing care for residents on Enhanced Barrier Protection. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: - Nursing staff will be in-serviced on control and protocols for setting up Enhanced Barrier Precautions. - Nursing staff will be in-serviced on dignity, closing doors and pulling privacy curtain during care. Nursing staff will be in-serviced on wearing proper PPE while doing care for residents on Enhanced Barrier Protection. - Nursing staff will be in-serviced about initiating proper care plans for residents who need care and Enhanced Barrier protection. Nursing staff will be in-serviced on wearing proper PPE while doing care for residents on Enhanced Barrier Protection. - Staff will be in-serviced to proper hygiene between glove changes. - Nursing staff will be in-serviced on control and protocols for setting up Enhanced Barrier Precautions. Nursing staff will be in-serviced on wearing proper PPE while doing care for residents on Enhanced Barrier Protection. Random QA audits will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audit will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Director of Nursing or a qualified Designee for a period of three months and until substantial compliance is met. Corrective action completion date: