Failure to Follow Infection Control Protocols and Maintain Safe Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the development and transmission of communicable diseases for three of five sampled residents. Staff did not follow the facility's Enhanced Barrier Precaution (EBP) policy, which requires the use of a gown and gloves during high-contact care activities for residents with certain conditions. Specifically, a Licensed Vocational Nurse (LVN) provided care to two residents on EBP precautions—one with a gastrostomy tube and another with a stage 4 pressure ulcer—without changing gown and gloves between residents, despite both the facility policy and staff interviews confirming this was required to prevent cross-contamination. Additionally, the facility did not ensure that a resident's oxygen tubing was kept off the floor. During observation, the oxygen tubing for a resident receiving oxygen therapy was found lying on the floor. Both the LVN and the Director of Nursing (DON) acknowledged that oxygen tubing should not be on the floor, as stated in the facility's policy and for infection control purposes. These deficiencies were identified through observation, interview, and record review, and involved residents with significant medical needs, including severe cognitive impairment, respiratory failure, gastrostomy, stage 4 pressure ulcers, and chronic obstructive pulmonary disease. The failures were directly related to staff not adhering to established infection prevention and control procedures during resident care activities.