Failure to Implement and Maintain Infection Control Precautions
Penalty
Summary
The facility failed to properly identify and implement necessary infection prevention and control measures for two residents requiring special precautions. One resident with wounds infected by Pseudomonas aeruginosa was not placed on Transmission Based Precautions (TBP), as there were no TBP orders, signage, or personal protective equipment (PPE) available outside the room or in the hallways. During wound care, a registered nurse performed hand hygiene and changed gloves but did not use a gown as required for TBP. Laboratory results confirming the infection were present in the resident's record, but appropriate precautions were not initiated. Another resident with an indwelling urinary catheter was not identified for Enhanced Barrier Precautions (EBP), and there were no EBP orders or signage posted. PPE was not available outside the resident's room or in common areas. During catheter care, a certified nursing assistant donned PPE but failed to maintain clean technique, touching contaminated surfaces and her own mask without changing gloves or performing hand hygiene before continuing care. This improper technique increased the risk of cross-contamination. Interviews with staff revealed inconsistent and insufficient training on infection control practices, including EBP and the correct use of PPE. Some staff were unclear about the requirements for EBP, and several had not received training on donning PPE. The former Director of Nursing was unfamiliar with the differences between EBP and TBP, and there was no clear leadership overseeing infection control responsibilities at the time of the survey.