Failure to Follow Infection Control Protocols and Report Outbreaks
Penalty
Summary
The facility failed to follow proper infection prevention and control protocols in several instances involving residents with infectious conditions and indwelling medical devices. For one resident on contact isolation for Clostridium difficile (C. diff), staff were observed delivering a lunch tray without wearing required personal protective equipment (PPE) such as gown and gloves, despite signage indicating transmission-based precautions. Additionally, a family member was present in the room without PPE and reported never being instructed to use it. Interviews with staff confirmed that all individuals entering a transmission-based precautions room should wear PPE, and that visitors should be educated and reminded to comply, but this was not consistently enforced. Another resident with an indwelling urinary catheter and under enhanced barrier precautions (EBP) was observed with their catheter bag resting on the floor, and a certified nurse assistant handled the bag without wearing gown or gloves. The CNA acknowledged the bag should not be on the floor and that it was missing a hook, but still failed to use appropriate PPE. The infection preventionist confirmed that EBP requires staff to wear gown and gloves during high-contact care activities, such as handling a catheter bag, to reduce infection risk. The facility also failed to report an outbreak of C. diff to local and state health departments, as required by policy. Infection surveillance data showed multiple positive cases over several months, meeting the facility's definition of an outbreak. The infection preventionist and director of nursing both acknowledged that the outbreak should have been reported to ensure proper guidance and resources for infection control, but this was not done. Facility policies reviewed confirmed the requirements for PPE use, catheter care, and outbreak reporting, which were not followed in these instances.