Infection Control Lapses in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents involving residents. In the first incident, a Certified Nursing Assistant (CNA) placed a nasal cannula (NC) that had fallen on the floor onto a resident's bed. The resident, who was dependent on supplemental oxygen due to Alzheimer's disease and other conditions, had a care plan indicating the need for oxygen therapy. The CNA's action of placing the NC on the bed after it had been on the floor was identified as an infection control issue by both the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), as it could lead to cross-contamination and potential infection. In the second incident, a CNA failed to perform hand hygiene and wear appropriate personal protective equipment (PPE) while providing activities of daily living (ADL) care to a resident on enhanced barrier precautions (EBP). The resident had a biliary drain, which required EBP to prevent infection. The CNA did not notice the EBP sign and proceeded to provide care without the necessary precautions, which was acknowledged by both the CNA and the LVN as a failure to adhere to infection control protocols. The Infection Preventionist and the DON confirmed that proper hand hygiene and PPE use were required to prevent the spread of infection. Both incidents highlight the facility's failure to adhere to its own policies and procedures regarding infection prevention and control. The facility's policies, which were last reviewed in December 2024, clearly outlined the need for proper handling of medical equipment and the use of PPE during high-contact activities. The deficiencies observed in these incidents had the potential to spread infections among residents and staff, as noted in the report.
Plan Of Correction
Necessary skills to complete the task prior to assisting residents with ADL care on 2/25/25. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken: Residents with oxygen therapy and those on Enhanced Barrier Precautions are potentially affected by the facility practice. C. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: The Infection Prevention Nurse will re-educate the nursing staff on or before 3/21/2025 re: the facility policy, "Enhanced Barrier Precautions," emphasizing identifying the residents who have EBP and the use of required PPE during cares involving direct contact on or before; and the policy Oxygen Therapy with emphasis on proper storage and handling to reduce the potential for transmitting respiratory infection. The Infection Prevention Nurse/designee will in-service newly hired certified nurse assistants at the time of hire and all direct care staff annually and as needed on the facility procedure Oxygen Therapy emphasizing infection control standards and proper storage of the tubing and nasal cannula to reduce the potential for transmission of respiratory infection. The DSD will in-service newly hired certified nurse assistants, at the time of hire, annually and when a variance to standard is identified on the facility hand hygiene and as needed on the facility procedure Enhanced Barrier Precautions to reduce the risk of transmitting infections and increased health risk for residents. D. How the facility plans to monitor its performance to make sure solutions are sustained: The Infection Prevention Nurse will conduct routine walking infection prevention rounds at least twice a week including monitoring staff for use of recommended PPE when providing care to residents with EBP and the placement and storage of oxygen tubing including nasal cannula to reduce the risk of transmitting infections and increasing health risks for residents. The Director of Nursing will monitor nursing staff performance or continued compliance with EBPS through observation, IPN reports and provide re-education or progressive disciplinary action as indicated. The DON/designee will report trends identified in EBP procedures to the Quality Assurance committee during the quarterly QA&A meeting for the purpose of process improvement changes to ensure continued compliance with this plan of correction. Allegation of Compliance Date: 3/25/2025.