Failure to Implement Infection Control Policies and Proper PPE Use
Penalty
Summary
The facility failed to implement and enforce infection prevention and control policies for residents on transmission-based precautions and during medication administration. For a resident with a confirmed Clostridium difficile (C. diff) infection and ongoing diarrhea, the facility posted Enhanced Barrier Precautions (EBP) signage instead of the required contact precautions. The resident's care plan did not include the use of a gown during care or when touching surfaces, and the EBP signage limited gown use, contrary to facility policy and CDC guidelines. Both the Infection Control Preventionist and the Director of Nursing confirmed that the correct signage should have indicated contact precautions. Multiple staff members were observed entering the room of a resident on contact precautions for a Klebsiella urinary infection without donning any personal protective equipment (PPE), such as gloves or gowns, as required by facility policy. The resident's care plan and physician orders specified contact precautions, but staff failed to comply during several observed interactions. The Director of Nursing acknowledged that staff were expected to use appropriate PPE in these situations. Signage outside a shared room for two residents—one with C. diff and one with a wound—was unclear, failing to specify which infection control practice (EBP or transmission-based precautions) applied to each resident. This lack of clarity was confirmed by staff interviews and review of care plans. Additionally, during medication administration, an LPN was observed picking up a dropped medication tablet with bare hands and placing it in a medication cup, contrary to facility policy, which requires staff to avoid direct hand contact with medications and to discard any contaminated tablets. The Director of Nursing confirmed this was not in accordance with policy.