Failure to Implement Effective Infection Control and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations of improper cleaning of resident equipment, inadequate hand hygiene, and inconsistent use of personal protective equipment (PPE) and Enhanced Barrier Precautions (EBP). Upon entry, staff were observed not wearing masks in resident areas despite a recent positive COVID-19 case among staff, and some staff only donned masks when they noticed the surveyor. Additionally, agency staff reported not receiving infection control training from the facility. For one resident admitted for rehabilitation after a stroke and with a pressure wound, a high-backed wheelchair was found with dried substances and debris, lacking a resident identifier. The same resident's bedside commode had visible dried brown residue, and a CNA was observed wiping the commode seat with a dry paper towel while wearing the same gloves used to empty a urine bucket, without performing hand hygiene or cleaning the commode frame. Both the physician and CNA involved in this resident's care did not perform hand hygiene before donning gloves, and neither knew the reason for the resident's EBP status. Another resident with a stage 3 pressure wound and indwelling catheter was observed with a catheter bag dragging on the floor and not properly placed in a privacy bag. Staff, including a therapist and CNAs, failed to perform hand hygiene before donning PPE and did not consistently wear gowns during high-contact care, despite EBP signage and orders. The resident's catheter tubing was repeatedly seen resting on the floor in common areas, and staff acknowledged that proper infection control procedures were not followed during care activities.