Infection Control Program Deficiencies and Lapses in Hand Hygiene
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple deficiencies in policy implementation, surveillance, and staff practices. The water management policy was outdated and lacked specific control measures to prevent the spread of Legionella, particularly in unoccupied rooms and a vacant wing. The infection preventionist and other staff acknowledged that flushing of water lines in these areas was not formally documented in the policy, and there was no clear process for addressing water stagnation. Infection surveillance logs for outbreaks of influenza and COVID-19 were incomplete, missing critical information such as symptom onset dates, staff last worked dates, test types and results, treatment parameters, isolation details, and resolution dates. The facility did not track or document the implementation of isolation precautions, PPE usage, or staff education during outbreaks. Additionally, the process for managing sick staff was informal, with untrained personnel making decisions about staff illness and return-to-work, and no formal tracking of staff testing or work locations during outbreaks. Direct care observations revealed that staff did not consistently follow hand hygiene protocols during personal care activities. In one instance, a CNA failed to perform hand hygiene after removing soiled gloves and before re-gloving while providing care to a resident on enhanced barrier precautions. Another resident with an indwelling catheter did not have enhanced barrier precautions initiated as required by facility policy. In a separate case, a CNA continued care after soiling gloves, wiped them clean instead of changing them, and did not perform hand hygiene after glove removal. These lapses were acknowledged by staff and supervisors as contrary to facility policy and training.