Failure to Implement Effective Infection Control Practices
Penalty
Summary
The facility failed to implement and maintain effective infection prevention and control practices for multiple residents. The Infection Preventionist did not accurately track or document infections, relying on memory rather than systematic trend analysis, and failed to record essential details such as onset dates and organism colony counts. In one instance, a resident was incorrectly listed as requiring contact precautions for a urinary tract infection, and the monthly infection tracking log lacked complete information as required by facility policy. Direct care staff were observed not following proper hand hygiene and glove use protocols. A Licensed Practical Nurse administered medication via a J-tube without performing hand hygiene before donning gloves. Certified Nurse Aides providing incontinent care to a resident on Enhanced Barrier Precautions did not wear required gowns and changed gloves multiple times without hand hygiene in between, despite clear signage and policy requirements. One CNA was unaware of the resident's precaution status, indicating a lack of communication or training. Additional lapses included a CNA using soiled gloves to assist a resident after providing perineal care, and failing to clean contaminated surfaces such as handrails after they were soiled during resident care. These actions were inconsistent with the facility's hand washing and infection control policies, which require glove changes and cleaning of contaminated equipment or surfaces to prevent the spread of infection.