Failure to Prevent Cross Contamination and Implement Infection Control Surveillance
Penalty
Summary
The facility failed to prevent cross contamination during clinical care and medication administration, as well as to implement an effective infection control surveillance plan. During a dressing change for one resident, an LPN placed a garbage bag on the overbed tray table and a disposable gown on the dresser, using the gown as a clean field for dressing supplies. The LPN did not clean the surfaces before or after the procedure, used PPE inconsistently, and failed to maintain proper hand hygiene throughout the dressing change. The LPN confirmed these lapses during an interview. During medication passes, two LPNs were observed using improper hand hygiene techniques, such as wiping hands with a washcloth soaked in hand sanitizer and returning it to the medication cart, and handling medications with bare hands. One LPN picked up a medication bottle lid from the floor and replaced it without performing hand hygiene, then continued preparing medications. These actions were confirmed by the staff involved during interviews. The facility also failed to implement and document an infection control surveillance plan in accordance with national standards. There was no line listing for COVID-19 or Influenza cases, and staff and residents were not tested according to established protocols. The infection preventionist was unfamiliar with outbreak management procedures, and symptomatic staff were not promptly tested for COVID-19. The Director of Clinical Operations and the Director of Nursing confirmed these failures in monitoring, tracking, and testing for infectious diseases.