Failure to Implement Effective Infection Control Program
Penalty
Summary
The facility failed to implement an effective infection prevention and control program in several key areas. For one resident who was suspected and treated for a highly contagious gastrointestinal condition, staff did not initiate contact precautions as required. Despite the resident experiencing multiple episodes of diarrhea and being treated with antibiotics for possible Clostridioides difficile (C. diff), there was no signage or personal protective equipment (PPE) outside the resident's room, and no documentation of transmission-based precautions in the facility records. Staff interviews revealed that precautions were not implemented while awaiting laboratory confirmation, contrary to facility policy, which allows for empiric precautions based on symptoms. Additionally, staff did not consistently clean and store shared medical equipment in a sanitary manner. During medication administration, an LPN was observed wiping a glucometer and blood pressure cuff with disinfectant wipes but then placing them directly on the resident's over-bed table without a barrier. The same staff member also failed to clean a thermometer after use and stored it with other equipment without proper disinfection. These actions were not in accordance with the facility's policy on routine cleaning and disinfection, which requires proper cleaning to prevent the development and transmission of infections. The facility also failed to promote good hand hygiene practices among direct care staff. Multiple staff members, including two LPNs and the DON, were observed with artificial and/or long fingernails extending beyond the fingertips, some of which were painted or acrylic. The DON acknowledged that anyone providing care should have clean, short fingernails, but the facility did not provide a dress code policy when requested. CDC guidance referenced in the report states that natural nails should not extend past the fingertip and artificial nails should not be worn when providing direct care, as germs can persist under artificial nails even after hand hygiene.