Infection Control Program Failures and Lapses in Staff Work Restrictions
Penalty
Summary
The facility failed to maintain its infection prevention and control program, resulting in several deficiencies related to the prevention and transmission of communicable diseases. Staff members with symptoms of COVID-19 were not restricted from working while awaiting test results, contrary to facility policy and CDC guidelines. Specifically, a CNA reported symptoms such as sneezing, headache, watery eyes, and back pain, which were communicated to the Director of Staff Development (DSD), but the CNA was allowed to continue working until the end of her shift and returned to work the following day. The CNA later tested positive for COVID-19. Similarly, an LVN who tested positive for COVID-19 continued to work until notified of her result, and there was a lack of immediate communication and follow-up regarding her work restriction. The Infection Preventionist (IP) and DSD did not ensure that symptomatic staff were promptly removed from the schedule, and the Director of Nursing (DON) and Administrator were not made aware of these lapses at the time they occurred. The facility also failed to maintain clean laundry equipment, as observed during an inspection of the laundry room. One washing machine was found with heavy buildup of black, yellow, and white sediments on various parts, despite claims of daily cleaning by the Housekeeping Supervisor. The IP confirmed that such buildup could serve as a breeding ground for bacteria and that equipment should be kept clean to prevent infection. This lack of proper maintenance of laundry equipment posed a risk of contamination for residents' laundry. Additional deficiencies were identified in the implementation of Enhanced Barrier Precautions (EBP) for residents with medical devices such as gastrostomy tubes (GT). During wound care for a resident with a GT, an LVN failed to don a gown before performing care, only putting it on after beginning the procedure. Another resident with a GT did not have EBP signage or precautions in place, despite care plan orders and policy requirements. Furthermore, a resident's meal tray was placed on a bedside table next to a used urinal containing urine, and there was no care plan documentation addressing the resident's preference to keep the urinal at the bedside. Staff interviews confirmed that this practice was not in line with infection control policies.