Failure to Maintain Effective Infection Prevention and Control Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in catheter care and adherence to enhanced barrier precautions. For one resident with a history of bacterial and urinary tract infections, the urinary catheter drainage bag was repeatedly observed lying on the floor and not placed in a dignity bag, contrary to facility policy and physician orders. Staff interviews confirmed awareness of the correct procedures, yet the catheter bag was left unsecured and in direct contact with the floor on more than one occasion. Another resident with multiple diagnoses, including muscle wasting and pressure ulcers, was also observed with a urinary catheter bag, tubing, and valve stem lying on the floor, despite staff acknowledging that this was not in compliance with infection control protocols. Additionally, during wound care for a resident under enhanced barrier precautions, staff failed to wear required personal protective equipment (PPE), specifically gowns, during high-contact care activities. While hand hygiene and glove use were observed, no gowns were worn by the LPN or CNAs assisting with the procedure, and staff expressed uncertainty about the requirements for gown use under enhanced barrier precautions. The PPE drawer near the resident's room was found to be empty at the time of observation, and staff interviews revealed confusion regarding the necessity of gown use during wound care, despite facility leadership providing clarification during the survey.