Infection Control Program Deficiencies and Environmental Sanitation Failures
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies in infection surveillance, documentation, and environmental sanitation. The Infection Preventionist (IP) did not accurately document the onset of infection symptoms, instead recording the antibiotic start date as the onset date for all residents on the surveillance logs. Additionally, infections were not properly classified as healthcare-associated (HAI) or community-acquired (CAI), with some being marked as recurrent, maintenance, or prophylactic without supporting documentation. The surveillance logs and infection screening evaluation forms contained inconsistent information, and the monthly mapping of infections did not include all cases or specify the microorganisms involved. Environmental observations revealed unsanitary storage of clean linens and resident personal items. In the laundry area, clean linens were stored near non-linen items such as keys, water bottles, and cleaning supplies, and clean curtains were not fully covered. Resident closets in multiple rooms contained exposed and disorganized diapers, gowns, and linens, some of which were stored on the floor or in contact with potentially contaminated surfaces. These conditions were verified by staff during interviews and acknowledged as having the potential for contamination. Direct care observations identified lapses in infection control practices related to indwelling medical devices. For example, one resident's indwelling urinary catheter bag and tubing were observed touching the floor, and another resident's urinary catheter privacy bag was seen dragging across the floor while the resident was in a wheelchair. Additionally, a resident with a permacatheter for hemodialysis did not have an order for evidence-based practices (EBP) for infection prevention, despite facility policy requiring such measures for residents with indwelling medical devices. These failures were confirmed by staff and through medical record review.