Failure to Implement Infection Control Program and Adhere to CDC Guidelines
Penalty
Summary
The facility failed to implement its Infection Prevention and Control program according to CDC guidelines and its own policies. In one instance, a resident under Enhanced Barrier Precautions (EBP) was not properly identified by staff, and staff members did not consistently perform hand hygiene or use required personal protective equipment (PPE) such as gowns and gloves during high-contact care activities. Staff members were observed entering the resident's room, transferring the resident, and changing bed linens without following EBP protocols, and some staff were unaware of the resident's EBP status or the correct procedures to follow. Additionally, the facility did not ensure proper disinfection of resident-care equipment. During a medication pass, an LPN used a vital signs cart and associated devices, such as a blood pressure cuff and pulse oximeter, without disinfecting them before or after use. The LPN also failed to observe the required drying time for disinfectant wipes, and staff interviews revealed a lack of knowledge regarding the specific disinfectants used and their proper application, including drying times. The facility also failed to maintain urinary catheter drainage bags off the floor for two residents with catheters. Observations showed that the drainage bags were repeatedly found lying on the floor, and staff did not correct this during care. Interviews with staff confirmed awareness that catheter bags should not be placed on the floor, yet the deficiency persisted across multiple observations.