Failure to Implement Infection Control Program and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observations and interviews. Staff did not disinfect shared mechanical lifts after use for two of three sampled residents, despite facility policy requiring disinfection between resident use. Specifically, a state trained nursing assistant was observed placing a mechanical lift into storage without cleaning it after use with a resident on Enhanced Barrier Precautions (EBP). Interviews with staff revealed inconsistent understanding and implementation of the cleaning protocol, with some staff stating lifts should be cleaned before and after each use, while others believed cleaning once per shift was sufficient. Additionally, a resident with a chronic vascular wound requiring daily dressing changes was not placed on EBP, contrary to both facility policy and updated CMS guidance. The resident was observed being transferred using a sit-to-stand lift without EBP signage on the door, and the lift and lift pad were not disinfected after use. The staff member involved acknowledged the oversight in not cleaning the equipment and not following proper procedures for handling the lift pad. Interviews with the infection preventionist, assistant director of nursing, and director of nursing revealed confusion and misinterpretation of the EBP policy, particularly regarding which residents require EBP. Some believed only residents with chronic wounds not following their healing trajectory needed EBP, while the policy and CMS guidance require EBP for all residents with chronic wounds or indwelling devices, regardless of healing status. The administrator confirmed expectations for staff to follow infection control policies, but observations and interviews demonstrated these were not consistently implemented.