Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures for several residents, leading to deficiencies in care. Resident 96, who was admitted with a shingles rash, was observed in communal areas with the rash exposed, despite having orders for contact isolation. The rash was not covered, and the resident was seen interacting closely with others, which posed a risk of spreading the infection. The infection control nurse confirmed that the rash should have been covered to prevent transmission. Additionally, the facility did not adhere to proper storage protocols for resident supplies, as observed in the bathrooms of Residents 62 and 77. Supplies such as bladder pads and maxi pads were stored directly on the floor, which could contribute to the spread of infection. These observations were confirmed with the Nursing Home Administrator and Director of Nursing. The facility also failed to implement Enhanced Barrier Precautions (EBP) for Resident 101, who had an indwelling urinary catheter. There was no visible signage outside the resident's room to indicate the need for EBP, and the facility's policy did not include guidelines for posting such signage. Interviews with staff confirmed the lack of proper communication and education regarding EBP, which is necessary to protect both residents and staff from potential infections.
Plan Of Correction
Facility cannot retroactively correct implementation of signs for EBP for resident 101. Resident 101 discharged from facility. Transmission based precautions have been discontinued for residents 96 due to resolution of condition. Items stored on the floor for residents 62 and 77 were moved and appropriately stored. Signage for residents with EBP have been moved to the outside of the door. There are currently no other residents on contact precautions. Resident rooms will be checked to ensure proper storage of personal hygiene products. The policy for EBP will be updated to reflect the use of signage and its placement. Nursing staff will be educated on policy change, maintaining contact precautions and storage of personal hygiene products. An audit of sign placement for residents on EBP will be completed weekly x 4 weeks. An audit for contact precautions compliance will be completed weekly x 4 weeks. Random audits of resident rooms for storage of personal hygiene products will be completed weekly x 4 weeks. Results of this audit will be reviewed by the Quality Assurance Committee to evaluate the need for ongoing auditing or further education.