Infection Control and Precaution Failures Identified
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices as evidenced by several observed deficiencies. The infection preventionist (IP) did not accurately classify residents according to McGeer's Criteria in the infection control surveillance reports for December 2024 and January 2025. This resulted in incomplete tracking of residents who did not meet the criteria for true infections, and the IP was unable to provide alternative documentation for this tracking. Additionally, the facility's antibiotic stewardship policies required review and notification of inappropriate antibiotic use, but the surveillance reports did not reflect this process. For a resident on neutropenic precautions following chemotherapy, the facility did not implement required measures. Despite a physician's order for neutropenic precautions, the resident's door was repeatedly observed open, and fresh flowers were present at the bedside, both of which are prohibited under the facility's policy. The IP was also observed entering the room without a mask, contrary to the stated requirements for staff and visitors to wear masks, keep the door closed, and restrict fresh flowers in the room. Another resident with an indwelling medical device was under enhanced barrier precautions, but a CNA was observed transferring the resident without wearing a gown, despite signage and orders indicating that PPE, including gowns, should be used during such care activities. Additionally, the sink in Medication Room A was found to be dirty, with visible discoloration and debris, and both the RN and DON confirmed that the sink required cleaning and maintenance, contrary to facility policy requiring medication preparation areas to be kept clean and sanitary.