Infection Control Deficiencies 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 resident with severe cognitive impairment and a Stage 3 pressure ulcer was on enhanced barrier precautions. However, during an observation, a Certified Nurse Aide and an LPN were seen providing incontinence care to this resident without wearing gowns, which was against the facility's policy for handling residents with wounds and indwelling medical devices. Both staff members acknowledged the oversight, with the CNA admitting they should have checked the precaution information before providing care. In the second incident, another resident with severe cognitive impairment and an indwelling urinary catheter was observed with the catheter drainage bag and a portion of the drainage tube lying on the floor. This was noted during two separate observations. An LPN confirmed that the drainage bag and tube should not be on the floor due to infection control concerns and stated that the privacy bag straps should be adjusted to prevent this. The CNA responsible for the resident's care admitted to missing the issue due to being busy.
Plan Of Correction
Plan of Correction: Approved April 23, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Actions for Residents Identified Infection Prevention & Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Resident #129 and #118 did not suffer ill effect from this deficient practice. Staff will follow Infection prevention and control guidelines in regards to EBP as well as other transmission-based precautions. Resident’s medical devices, such as indwelling catheter/tubing will be placed in proper position and avoid touching the floor to prevent contamination. Resident #118 foley drainage tube, foley bag and privacy bag were immediately changed upon notification of this deficiency. This resident was assessed and found to have not [MEDICATION NAME] negative effects as a result of this deficiency. License Practical Nurse #15 and Certified Nurse Aide #14 were both re-educated on the facility’s infection control Policy and the need to ensure that residents foley drainage bags or tubes do not touch the floor. Resident #129 was assessed and found to have no signs of infection, no other signs of negative effects as a result of this deficiency. License Practical Nurse 21 and Certified Nurse Aide 20 were both re-educated on the facility’s Enhanced Barrier Precaution Policy and Procedure and the need to wear the recommended PPE. Monitoring for any signs of infection will be ongoing for this resident. Residents at Risk Any resident can be affected by this deficient practice. The Director of Nursing conducted an audit to identify any other resident that may have been affected by this deficient practice and no other resident was identified. The facility respectfully states that while all residents had the potential to be affected by this deficiency, no other resident was found to be affected. Systemic Changes All staff will be provided in-service education in regards to EBP/Transmission based precautions by Infection Preventionist/Nurse Staff Educator/Designee. All nursing staff (Nurses and CNA’s) will receive in-service education in regards to proper placement of indwelling catheter tubing when residents are in and out of bed to prevent tubing touching the floor. The Administrator reviewed the facility’s infection control and Enhanced Barrier Precaution Policies and found them to be in compliance with all local, state and federal regulations. The Director of Nursing will initiate Infection Control and Enhanced Barrier Precaution re-education for all staff. Monitoring of Corrective Actions The DON has created an audit to monitor foley drainage bags and tubes not touching the floor. The DON has also created an audit to monitor compliance with PPE usage for all residents on EBP. Audits will be conducted on indwelling catheter placement in/out of bed for those residents that are applicable. Audits will be performed every shift x 1 week, daily x 2 weeks, then monthly x 3 months. Audits will be completed by Infection Preventionist/Unit Manager/Staff Nurse/Nurse Supervisor/Designee. Audits will be conducted on all units in regards to staff use of EBP, to include signage outside of applicable rooms/Donning & Doffing of PPE. Audits will be performed every shift x 1 week, then daily x 2 weeks, then monthly x 3 months. Audits will be completed by Infection Preventionist/Unit Manager/Staff Nurse/Nurse Supervisor/Designee. Audits will be presented at QAPI meetings monthly by the DNS to determine continued need. Review of nursing staff attendance and completion of education will be monitored by Infection Preventionist/Nurse Staff Educator/ADON/DNS/Designee. The DNS/Designee will be responsible for completion of this plan of correction. Responsible: The DNS/Designee will be responsible for completion of this plan of correction. Completion Date: 5/31/2025