Failure to Implement Effective Infection Prevention and Control Practices
Penalty
Summary
The facility failed to implement an effective Infection Prevention and Control Program (IPCP) for multiple residents, as evidenced by direct observations, interviews, and record reviews. Staff did not consistently follow Enhanced Barrier Precautions (EBP) for residents with wounds, indwelling devices, or those at risk for multidrug-resistant organisms (MDROs). For example, staff were observed providing care to residents on EBP without donning gowns, despite facility policy and posted signage requiring gown and glove use during high-contact care activities. In the Memory Care Unit, gowns were not available in designated storage areas, and daily PPE audits were not consistently performed. Staff interviews revealed gaps in knowledge and inconsistent adherence to EBP protocols, with some staff only using gowns for specific conditions like scabies, and others citing lack of PPE accessibility as a barrier to compliance. Additional deficiencies were identified in the management of indwelling catheter and vascular access devices. One resident with bilateral nephrostomy tubes was observed with drainage bags improperly positioned—one on the floor and another under the pillow—contrary to facility policy requiring drainage bags to be kept off the floor and below bladder level. Staff interviews confirmed awareness of the correct procedure, but the practice was not followed. Another resident with a PICC line had a dressing that had not been changed in accordance with the facility's policy and physician orders, with the dressing date indicating it had not been changed since hospital admission. Documentation in the Medication Administration Record (MAR) did not match physical evidence, and the DON was unable to provide proof of dressing changes as required. Further, staff were observed providing urinary catheter care and changing adult briefs for a resident with multiple indwelling devices and wounds without wearing gowns, despite clear signage and policy requirements. The RN Unit Manager did not intervene when observing this non-compliance. Staff interviews indicated that the omission was due to being in a hurry, and there was a lack of consistent understanding and enforcement of PPE protocols. These failures in infection control practices placed residents at risk for the transmission of MDROs and did not align with the facility's stated IPCP policies.