Infection Control Deficiencies and Failure to Follow Protocols
Penalty
Summary
The facility failed to implement and maintain effective infection prevention and control practices as outlined in its own policies and procedures. Surveyors found that the monthly Infection Prevention and Control Surveillance Logs for January and February did not accurately match the Infection Control Monthly Summary reports, resulting in inaccurate reporting of healthcare-associated infections (HAIs) and community-acquired infections (CAIs). The Infection Preventionist (IP) confirmed that the discrepancies were due to the volume of infections and acknowledged that the numbers should have matched to provide accurate information for infection control monitoring. Additionally, the facility did not follow Enhanced Barrier Precautions (EBP) for a resident with a central line, as there was no signage or personal protective equipment (PPE) available at the doorway, and no physician's order for EBP was documented. Staff also failed to adhere to hand hygiene protocols during resident care activities. For example, an occupational therapist did not perform hand hygiene between assisting multiple residents during mealtime, and a licensed vocational nurse (LVN) did not don a gown when providing enteral feeding care to a resident on EBP. Another LVN failed to perform hand hygiene and change gloves prior to administering insulin to a resident, despite facility policy requiring these steps to prevent infection. Furthermore, improper hand hygiene was observed during wound care treatment for a resident with stage 4 pressure injuries. The LVN performing the wound care did not sanitize hands immediately after removing gloves throughout the procedure, only washing hands at the end of the treatment. These failures were acknowledged by the staff involved and confirmed by the IP and Director of Nursing (DON) during interviews, demonstrating a lack of consistent adherence to infection control protocols designed to prevent the development and transmission of diseases and infections within the facility.