Failure to Implement Infection Prevention and Control Measures
Penalty
Summary
The facility failed to implement its infection prevention and control program for 58 out of 91 sampled residents by not initiating appropriate measures after a certified nursing assistant (CNA) was diagnosed with scabies. The CNA had worked multiple shifts and had direct contact with numerous residents before being diagnosed. Despite the CNA notifying the Director of Staff Development (DSD) about her diagnosis and expressing concerns about a possible outbreak, the DSD did not immediately notify the Infection Preventionist (IP), and no timely line listing, contact tracing, or monitoring was initiated. The facility's own policies required immediate communication and surveillance in such cases, but these were not followed, and only a limited number of residents with rashes were later identified and seen by a dermatologist. Staff also failed to use proper personal protective equipment (PPE) during high-contact care activities. In one instance, a licensed vocational nurse (LVN) provided direct care to a resident on Enhanced Barrier Precautions (EBP) due to a dialysis port without donning the required PPE. The LVN acknowledged the lapse and stated that gloves, gown, and mask should have been used. Additionally, for another resident with a gastrostomy tube and an EBP order, there was no PPE or EBP signage posted outside or inside the room, and staff confirmed that EBP should have been implemented immediately upon admission or readmission. Other infection control lapses included a nasal cannula being left on the floor while in use for a resident receiving oxygen, which staff recognized as a risk for infection. Furthermore, a resident with an active infection requiring contact isolation was cohorted with another resident who had a dialysis catheter, contrary to facility policy that prohibits such cohorting when the roommate has invasive devices. These failures were confirmed by staff interviews and review of facility policies, which outlined the necessary precautions and procedures that were not followed.
Plan Of Correction
F880: Infection Prevention and Control CORRECTIVE ACTION On 3/6/2025, IP nurse started the line listing and isolation for residents who were exposed to CNA 12. On 3/7/2025, the residents who were exposed to CNA 12 were put on isolation precautions. On 3/7/2025, LVN 3 was provided an in-service regarding the importance of following isolation protocol. Sign for EBP was posted and isolation cart was put outside of resident 68's room on 3/6/2025 by the IP nurse. CORRECTIVE ACTION (CONTINUED) On 3/5/2025, the oxygen tubing was immediately replaced by the charge nurse. On 3/3/2025, resident 27 was already off isolation. OTHER RESIDENTS AFFECTED IDENTIFICATION On 3/13/2025, residents who were not in CNA 12's run but had rashes were put on isolation precautions. On 3/14/2025, residents who were exposed to CNA 12 who had rashes and residents who were not in CNA 12's run but had rashes had skin scrapings done to test for scabies. On 3/17/2025, the results for the skin scraping were negative for all the tested residents. Isolation precautions were removed. On 3/10/2025, CNA 12 was cleared back to work by the IP nurse. On 3/7/2025, the IP nurse reviewed all residents that needed to be on EBP and checked if there were any other rooms that needed signage, and appropriate PPE was provided outside of the room. No other resident was affected by the deficient practice. CORRECTIVE ACTION (CONTINUED) On 3/5/2025, the oxygen tubing was immediately replaced by the charge nurse. On 3/3/2025, resident 27 was already off isolation. OTHER RESIDENTS AFFECTED IDENTIFICATION On 3/13/2025, residents who were not in CNA 12's run but had rashes were put on isolation precautions. On 3/14/2025, residents who were exposed to CNA 12 who had rashes and residents who were not in CNA 12's run but had rashes had skin scrapings done to test for scabies. On 3/17/2025, the results for the skin scraping were negative for all the tested residents. Isolation precautions were removed. On 3/10/2025, CNA 12 was cleared back to work by the IP nurse. On 3/7/2025, the IP nurse reviewed all residents that needed to be on EBP and checked if there were any other rooms that needed signage, and appropriate PPE was provided outside of the room. No other resident was affected by the deficient practice. On 3/5/2025, the IP nurse went into the other residents' rooms to check if there are any other oxygen tubing that needed to be replaced. No other resident was affected by the deficient practice. On 3/5/2025, the IP nurse reviewed all isolation orders and verified that they were carried out. No other resident was affected by the deficient practice. On 3/7/2025, resident 62 was assessed to check if there are any infections that were received during cohorting. No negative findings were found. MEASURES AND SYSTEMIC CHANGES On 3/12/2025, the IP nurse/designee started to provide in-services to staff regarding the importance of following isolation protocol and proper PPE for EBP. IP nurse/designee provided an in-service regarding the importance of clear communication between departments, especially regarding infectious conditions like scabies, starting on 3/7/2025. ON 3/21/2025, the clinical consultant provided additional in-service to the DSD and IP regarding the importance of clear communication between departments, especially regarding infectious conditions like scabies. On 3/10/2025, the IP nurse provided an in-service to department heads regarding the daily (Monday to Friday) room rounds to check for oxygen tubing on the floor and replace them as needed. During the daily (Monday to Friday) standup meeting, the department heads will discuss any infection control concerns, including staff and resident being exposed to infectious diseases. Starting 3/10/2025, the IP nurse/designee will do daily rounds to check if staff are following infection control protocols including wearing proper PPE during care for residents on EBP. During the daily (Monday to Friday) standup meeting, the department heads will discuss and correct any found oxygen tubing on the floor. During the daily (Monday to Friday) standup meeting, the DON/designee will review new admissions and verify if isolation/EBP is needed and was carried out. PERFORMANCE MONITORING DON/designee will report any findings/trends during monthly QAA meeting for review x90 days or until substantial compliance has been met.