Failure to Implement and Maintain Infection Control Program and Contact Precautions
Penalty
Summary
The facility failed to implement and maintain a comprehensive infection prevention and control program, specifically in the case of a resident diagnosed with Respiratory Syncytial Virus (RSV). Despite a physician's order to initiate contact precautions following a positive RSV laboratory result, no signage or personal protective equipment (PPE) was present outside the resident's room for over 24 hours. Multiple observations confirmed the absence of required precautions, and staff interviews revealed a lack of awareness regarding the need for contact precautions for the affected resident. The facility's own policies required the use of contact precautions for residents with RSV, including the use of gloves and gowns and appropriate signage, but these were not followed in practice. The resident involved had significant medical conditions, including chronic obstructive pulmonary disease (COPD) and severe cognitive impairment, as indicated by a low BIMS score. The failure to implement contact precautions was confirmed by both the DON and NHA, who acknowledged that the precautions were not put in place until prompted by surveyor inquiry, well after the physician's order was issued. Staff responsible for the resident's care were either unaware of the need for precautions or did not have the necessary resources available to implement them. Additionally, the facility's infection prevention and control program was found to be deficient in its surveillance and data analysis functions. The infection Preventionist had not kept up with infection control data analysis, and surveillance logs were incomplete, lacking critical information such as resident location, organism identification, infection onset dates, and whether infections were facility- or community-acquired. The NHA confirmed that the facility did not have a functional system for tracking infection clusters or analyzing changes in infection trends for several months, further contributing to the deficiency.