Infection Control Deficiencies: Incomplete Surveillance, Improper PPE, and Hand Hygiene Failures
Penalty
Summary
The facility failed to implement an effective infection prevention and control program as evidenced by incomplete infection surveillance, improper use of personal protective equipment (PPE), and inadequate hand hygiene practices among staff. The infection surveillance logs for January, February, and March 2025 were missing critical data such as infection site, organism, lab/culture results, symptoms, isolation/precautions, and whether infections were acquired in the facility. Additionally, there was no infection surveillance conducted for April 2025, and the designated Infection Preventionist had not received appropriate training. During direct care, staff did not adhere to Enhanced Barrier Precautions (EBP) for a resident with multiple medical diagnoses, including paraplegia and a urinary tract infection, who had an indwelling urinary catheter and intravenous catheter. Certified Nursing Assistants provided high-contact care activities such as peri-care, catheter care, and transfers without wearing required isolation gowns, although they did change gloves and sanitize hands between tasks. Nursing staff also failed to perform proper hand hygiene during medication administration and resident assessments. One nurse wore the same gloves while performing multiple tasks, including blood glucose checks and handling the medication cart, without changing gloves or performing hand hygiene. Another nurse moved between residents and tasks, such as adjusting oxygen tubing, checking blood glucose, and administering medications, without performing hand hygiene between residents or tasks. These actions were inconsistent with the facility's hand hygiene policy, which requires hand hygiene before and after resident care, between tasks, and between residents, regardless of glove use.