Failure to Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for several residents, as evidenced by multiple staff not adhering to hand hygiene protocols and improper handling of medical equipment. During medication administration, two LVNs were observed not performing hand hygiene between residents, despite facility policy and their own acknowledgment of its importance. This occurred with multiple residents, some of whom had varying levels of cognitive impairment, and was confirmed through both observation and staff interviews. The facility's policies required hand hygiene before administering medication and between resident care, but these were not followed. Additionally, a resident's oxygen nasal cannula tubing was found resting on top of the oxygen concentrator and in direct contact with the wall, rather than being stored in a protective bag as required by facility policy. Staff interviews confirmed that this was not in accordance with procedures and could lead to cross contamination. The resident in question had a history of chronic obstructive pulmonary disease and acute respiratory failure, and was actively receiving oxygen therapy per physician orders. Further, a CNA was observed failing to perform hand hygiene after leaving one resident's room and before entering and exiting another resident's room, even after providing assistance. Both the CNA and other staff acknowledged the importance of hand hygiene to prevent cross contamination, and the facility's policy required hand hygiene upon entering and exiting resident rooms. These lapses were confirmed through direct observation, staff interviews, and review of facility policies.