Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement its infection prevention and control program according to its policies and accepted standards of care. Staff members, including an LVN and a CNA, did not follow proper infection control procedures when entering and leaving rooms under contact/droplet precautions for COVID-19, such as not performing hand hygiene, not wearing required PPE, and contaminating clean meal carts with items from isolation rooms. Additionally, a nurse was observed entering a COVID-19 positive room without an N95 mask, and another staff member left a COVID-19 isolation room without proper PPE and failed to perform hand hygiene. Environmental issues were also identified, including the presence of paper trash and a staff personal item in the clean linen area, and improper storage and labeling of urinals in resident rooms and restrooms. A finished meal tray was placed on a PPE cart instead of a designated meal cart, and a urinal was stored next to a resident's meal tray and drinking liquids. These actions were verified by staff during interviews and were not in accordance with the facility's infection control policies. The facility's infection control surveillance did not include residents with signs or symptoms of infection, and staff failed to wear proper PPE when administering medications via gastrostomy tube (GT) to a resident on enhanced barrier precautions. Additionally, a stethoscope used for checking GT placement was not sanitized after use. These failures were acknowledged by staff and the Director of Nursing during interviews, and the facility was experiencing a COVID-19 outbreak at the time.