Repeated Deficiencies in Infection Control Protocols
Penalty
Summary
The facility failed to implement effective plans of action to address quality deficiencies related to infection prevention and control protocols. Specifically, the facility did not follow control protocols in the east side soiled utility room and failed to implement hygiene protocols for a resident. This deficiency was identified during a recertification survey, where it was noted that the facility had previously been cited for similar issues. The survey history revealed that during a previous recertification survey, the facility was cited for failing to implement control procedures for three residents out of a sample of 28. This indicates a repeated pattern of deficient practices in infection prevention and control, which the facility has not adequately addressed. The Director of Nursing confirmed that the facility holds monthly Quality Assurance and Performance Improvement (QAPI) meetings, involving various department heads, to review deficiencies and track corrective actions. Despite these meetings and efforts to monitor quality assurance, the facility's actions have not been effective in preventing repeated deficiencies. The failure to follow established protocols in the soiled utility room and for the resident's hygiene suggests a lack of systematic implementation and monitoring of infection control measures. This ongoing issue affects the facility's ability to provide safe and effective care to its residents.
Plan Of Correction
F-867 QAPI/QAA Improvement Activities Identify patients that were at risk and what did: Initially, the management team created a QAPI from the initial exit with areas of concerns. We started immediate in-services since and changed systems and strengthened our quality assurance process and created all new tracking tools. Once the final 2567 came through, we updated the audits and worked on our plans as a team. Ref F880 QAPI action Plan: Once identified by the surveyor, all staff that distribute meal service were reeducated on the process of Donning and Doffing when entering a room with droplet precautions. Once identified by the surveyor, resident #57 was assessed and is in stable condition. Regarding the staff member that double gloved, she was counseled on not following proper control procedures. Once identified by the surveyor, all staff were reeducated on the process of hygiene and also were provided individual education with acknowledgment. All staff were in-serviced on keeping the Common and the Pantry areas cleaned with no trash to be found on the floor, and this was done on. Once identified by the surveyor, the batteries were replaced by the Director of Plant Operations and is now monitoring randomly to ensure that the battery-operated lock system is working regularly. All shower rooms are the responsibility of any staff member that enters the shower room to take a resident into the shower room; there will be no cartons or food-related permits nor masks in the shower room. Resident tubing touching the floor education was done on. When a patient is on droplet precaution, we will do all possible to keep doors closed at all times. If the resident cannot comply due to mental state or is at risk, the team will care plan and possibly look for alternatives to include discharge. We will always try to mediate the issue for compliance with standards. We also have to honor the fact that this is their home and will work on reasonable accommodations. How will you identify other patients that are at risk: Ref F880 QAPI action Plan: Besides the care nurse, all staff were re-educated on control procedures on (25). Also, the Administrator and DON along with the QAPI committee met to review the policies again and to ensure staff education is reinforced with additional in-services. New tools were created to help with tracking and trending and ensuring that not only this citation is followed on the monthly QAPI Review but have a purposeful tracking and trending system with education and return demonstrations when applicable. Measures put in Place: Besides the care nurse, all staff were re-educated on control procedures on (25). Also, the Administrator and DON along with the QAPI committee met to review the policies again and to ensure staff education is reinforced with additional in-services. New tools were created to help with tracking and trending and ensuring that not only this citation is followed on the monthly QAPI Review but have a purposeful tracking and trending system with education and return demonstrations when applicable. The following identified areas were used for education to staff and will be maintained on our QAPI for the remainder of the year for tracking and trending data: F583-(N202) Personal Rights and Confidentiality F-645 PASSAR Screening F-656- (N054 and N072) Develop and Implement Care Plans F-761-(N095)- Label Drugs and Biologicals F-842- Resident Records Identifiable Information F-814 Dispose Garbage and Refuse Property F-867- QAPI/ QAA Improvement Activities F-880- Control Control Plan - Proper techniques of Donning and Doffing - Droplet vs Enhanced Barrier Precaution - Meal tray distribution - Transmission Based Precautions Hygiene - High Touch areas - Linen Handling including clean and soiled - Cath Tubing not touching the floor Nursing focus will include: - Cath Care - Environmental Common area and Pantry Care - Soiled utility locks to ensure that they are functional How will you monitor: The Administrator and Director of Nursing will be responsible for bringing the findings and summary to the QAPI Committee. This will occur monthly for 3 months, then quarterly and/or if any variances are reported ongoing. Since QAPI was identified as needing improvement, we have changed the reporting and all citations will have a structured monitoring designated by accountable reporting, trending, analysis, and follow-through.