Failure to Implement Infection Control Precautions and Equipment Cleaning
Penalty
Summary
The facility failed to implement its infection prevention and control program as required, specifically regarding contact isolation precautions for residents with positive multidrug resistant organisms and the cleaning of shared medical equipment. Multiple staff members, including CNAs, LPNs, and restorative aides, were observed entering rooms of residents on contact or enhanced barrier precautions without performing hand hygiene or donning appropriate personal protective equipment (PPE) such as gowns and gloves. In several instances, staff entered isolation rooms, provided care, or handled resident equipment without following established protocols, and visitors were also seen entering isolation rooms without PPE or hand hygiene. Additionally, staff failed to clean and disinfect glucometers between resident uses during blood sugar checks, as observed with several residents. The facility's infection prevention nurse and interim director of nursing both confirmed that staff are expected to clean glucometers with disinfecting wipes between each use, and that PPE and hand hygiene are required when entering contact isolation rooms. However, observations showed that these practices were not consistently followed, and staff demonstrated confusion or lack of knowledge regarding when PPE was required and the reasons for resident isolation. The report also notes that some residents with confirmed infections, such as C. difficile, were not promptly placed on contact isolation, and care plans were not updated to reflect current infection status or required precautions. There were inconsistencies in the application of isolation signage and communication among staff regarding residents' isolation status. The facility's own policy requires contact precautions for residents with certain infections, use of dedicated or disinfected equipment, and proper PPE use, but these were not adhered to during the survey period.