Failure to Implement Effective Infection Control Program and Precautions
Penalty
Summary
The facility failed to establish and implement an effective Infection Prevention and Control Program (IPCP), as well as to update IPCP policies annually. The Infection Preventionist (IP) was unable to demonstrate infection surveillance for symptomatic residents who had not been diagnosed with an infection and lacked methods for investigating infections. The IP tracked only residents prescribed antibiotics, without documenting symptoms or using established criteria to determine infections. The IP also did not investigate the origin of infections, analyze clusters, or determine the organism and source of infection. Employee illnesses were not tracked prior to January 2025, and there was no correlation monitoring between resident and employee illnesses. The facility's Infection Control Committee (ICC) was not active, and required meetings and policy reviews were not conducted. Several IPCP policies and procedures were outdated and had not been reviewed or updated annually as required. The facility also failed to implement enhanced barrier precautions (EBP) and proper hand hygiene during resident care and medication administration. For one resident with multiple unhealed wounds and a recent surgical amputation, staff did not wear protective gowns during high-contact care activities, despite clear signage and physician orders for EBP. Staff members, including a CNA, RN, occupational therapist, and physical therapist, were observed providing care without the required protective equipment. The CNA was unaware of the reason for EBP signage and could not distinguish between transmission-based precautions and EBP. Additionally, an LPN was observed repeatedly failing to perform hand hygiene before and after administering oral and inhaled medications to multiple residents. The LPN donned gloves without sanitizing hands and did not perform hand hygiene after glove removal or between medication passes, contrary to facility policy. The LPN acknowledged forgetting to perform hand hygiene during medication administration. Facility policies required handwashing before and after medication administration, but these procedures were not followed during the observed medication passes.