Failure to Implement and Maintain Infection Control Practices
Penalty
Summary
The facility failed to implement and maintain effective infection prevention and control practices in several key areas, as observed and documented by surveyors. Staff did not consistently follow Enhanced Barrier Precautions (EBP) for residents with high infection risk, such as those with tracheostomy tubes or recent tracheostomy removal, during high-contact activities in the therapy gym. Specifically, staff members assisted residents with transfers and mobility without wearing required gowns and gloves, despite care plans and facility policy indicating the necessity of these precautions. Interviews with staff and review of CDC guidance confirmed that EBP should be followed during such activities, both inside and outside resident rooms. Additionally, the facility failed to properly clean and disinfect cloth gait belts used for resident transfers. Staff were observed using disinfecting wipes intended for hard, non-porous surfaces on cloth gait belts, contrary to manufacturer instructions and facility policy. This practice was acknowledged by the Infection Prevention Nurse as ineffective for porous materials like cloth, raising concerns about the potential for cross-contamination. The improper handling and storage of resident care items extended to other areas, such as oxygen tubing being allowed to touch the floor and urinals being hung on trash cans containing waste, both of which were confirmed by staff as inappropriate and against facility policy. Environmental deficiencies were also noted, including the presence of ripped and gouged foam bed rail padding that could not be properly cleaned, and the improper storage of medical supplies in a dirty storage room with personal items placed on top of supply boxes and boxes stored directly on the floor. Staff interviews and policy reviews confirmed that these practices did not align with facility protocols for maintaining a clean and safe environment, and could contribute to the transmission of infectious microorganisms among residents.