Failure to Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by improper hand hygiene and incorrect disposal of personal protective equipment (PPE) during resident care. In one instance, a certified nurse assistant (CNA) removed gloves and left a resident's room to retrieve linen before sanitizing hands, while a registered nurse (RN) cleaned a resident's perineal area without changing gloves after cleaning a bowel movement. Both staff members acknowledged during interviews that proper hand hygiene and glove changes were required to prevent infection, as outlined in facility policy and CDC guidelines. Additionally, staff did not correctly dispose of a gown used during care for a resident on Enhanced Barrier Precautions (EBP), leaving the gown on a chair outside the resident's room and failing to post required EBP signage. The infection preventionist confirmed the resident was on EBP and that signage had not been replaced after falling down. Interviews with the infection preventionist, director of nursing, and administrator confirmed expectations for staff to follow infection control policies, including proper PPE disposal and hand hygiene, which were not met in these observed instances.