Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to its infection prevention and control protocols, as evidenced by several observations and interviews. Staff were seen entering rooms of residents under contact and droplet precautions without wearing the appropriate personal protective equipment (PPE), such as gowns, gloves, and masks. This was particularly noted during the distribution of meal trays, which poses a risk of spreading communicable diseases. Additionally, there were instances of improper hygiene practices, such as double-gloving during care, which is against the facility's policy. Resident #57, who was admitted with an unspecified open wound, was found to have a care plan that included the use of an air mattress, offloading heels with pillows, and turning and repositioning every two hours. However, the care nurse reported that the resident was non-compliant with treatment and medications, which could potentially slow down the healing process. The resident was also on enhanced barrier precautions due to the open wound, yet the care provided did not fully align with the established protocols. Environmental issues were also noted, such as trash and food on the floor of the resident's pantry room, which is supposed to be cleaned by housekeeping staff. The soiled utility room door was found to be unable to lock, posing a security risk. Additionally, there were observations of oxygen tubing touching the floor, which could lead to contamination. These findings indicate a lack of adherence to the facility's infection control policies and procedures, contributing to the overall deficiency in maintaining a safe and sanitary environment.
Plan Of Correction
F 880 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 for 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 [insert date]. Once identified by the surveyor, the batteries were replaced by the Director of Plant Operations and are now being monitored 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 items nor masks in the shower room. Resident tubing touching the floor education was done on [insert date]. 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: 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. The system was reevaluated by the QAPI Committee, and education was required for all staff since all residents were at risk as a facility-wide initiative. 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: The following identified areas were used for education to staff: - 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 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 System Response: 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 for 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 [insert date]. Once identified by the surveyor, the batteries were replaced by the Director of Plant Operations and are now being monitored 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 items nor masks in the shower room. 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. 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: - F583-(N202) Personal Rights and Confidentiality - F-645 PASSAR Screening - F-656- (N054 and N072) Develop and Implement Care Plans - Cath Care - Environmental Common area and Pantry Care - Soiled utility locks to ensure that they are functional - K353 Tags Sprinkler System - K355- Tags- Sprinkler Regulations Maintenance and Testing - K 741 Smoking regulations - K-918 Essential Electrical Systems - K923 Cylinder and Container Storage 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.