Failure to Implement and Communicate Proper Infection Control Precautions
Summary
Surveyors observed that a resident with multiple medical conditions, including influenza and a right artificial knee joint, was not provided with appropriate infection control measures during therapy and care activities. On one occasion, there was no Enhanced Barrier Precautions (EBP) signage or PPE cart available in the resident's room, despite the resident later being placed on EBP. When the PPE cart was present, it was inadequately stocked, containing only gowns and lacking gloves and hand sanitizer. Physician orders for EBP were not written until after these deficiencies were observed, and care plans did not address the resident's need for EBP or droplet precautions following a positive influenza diagnosis. Documentation revealed that the resident developed a wound on the right knee with purulent drainage, yet infection control protocols were not consistently implemented. Staff interviews indicated confusion and inconsistency regarding the use of PPE and the posting of appropriate signage. The infection preventionist and DON acknowledged that staff actions did not align with facility policy or training, and that signage in use did not specify the type of precautions or required PPE, instead instructing individuals to 'see nurse' for information. This created uncertainty for staff and visitors about the necessary infection control measures, especially when a nurse was not immediately available. Facility documents outlined clear requirements for PPE availability, signage, and procedures for both EBP and droplet precautions, but these were not followed in practice. The lack of accessible and specific precaution signage, incomplete PPE supplies, and delayed implementation of physician orders and care plans contributed to the deficiency in infection control practices for the resident. These failures were confirmed by both the infection preventionist and DON during interviews.
Penalty
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