Failure to Implement Infection Prevention and Control Practices
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices for multiple residents, as evidenced by surveyor observations, interviews, and record reviews. For one resident with a history of vancomycin-resistant enterococcus (VRE), staff did not implement Enhanced Barrier Precautions (EBP) as ordered, including the absence of required signage and personal protective equipment (PPE) at the room entrance. Staff members entered the resident's room and provided care, such as medication administration and linen changes, without wearing gowns, contrary to facility policy and physician orders. The Infection Preventionist and Director of Nursing confirmed that EBP should have been implemented for this resident due to their history of multidrug-resistant organisms (MDROs), but it was not done. In another instance, a Restorative Nursing Aide used a cloth gait belt with a resident on EBP and failed to properly disinfect it between uses. The aide stated she used bleach wipes on the cloth gait belt and then used it with another resident. The Infection Preventionist clarified that cloth gait belts are porous and cannot be properly disinfected with wipes, and that only vinyl gait belts should be used. The Director of Nursing confirmed that improper disinfection of shared equipment could lead to the spread of infection. Additionally, multiple medication carts were found with Prostat supplement bottles that were sticky and had visible drippings, indicating they were not cleaned before and after use as required by facility policy. Further deficiencies included staff not wearing gowns during high-contact care activities for residents on EBP, such as providing bed baths, and not securing gowns properly during medication administration. Linen carts were observed with loosely woven mesh covers that did not fully protect linens from dust. In the respiratory care area, a BiPAP mask was not stored in a manner free from contamination, and the nebulizer was not labeled with the resident's name or date last changed. Documentation and cleaning of the BiPAP equipment were inconsistent and not in accordance with physician orders or manufacturer instructions. These practices were confirmed by staff interviews and policy reviews, demonstrating a failure to follow established infection control protocols.