Failure to Implement Infection Control Policies and Equipment Cleaning
Penalty
Summary
The facility failed to implement its infection prevention and control policies and procedures in several key areas, including the management of Clostridioides difficile (C. diff) infection, cleaning of reusable resident-care equipment, and proper hand hygiene. For one resident with an active C. diff infection, the care plan inaccurately listed an antiviral medication as an intervention, despite C. diff being a bacterial infection. The care plan and Kardex specified contact precautions but did not include further interventions for the resident or their roommate, who was ambulatory and at risk of spreading contamination due to frequent movement around the facility. Staff did not ensure that the roommate washed hands with soap and water before leaving the room, nor was the resident's walker cleaned after use, despite the risk of contamination. Observations revealed that staff did not consistently follow hand hygiene protocols specific to C. diff, such as washing hands with soap and water instead of using alcohol-based hand rubs, which are ineffective against C. diff spores. A certified nurse aide was observed leaving the room of a resident with C. diff without washing hands appropriately and was unaware of the correct protocol. Additionally, laundry staff had not been educated on handling linens contaminated with C. diff, and soiled linens were sometimes transported in regular bags instead of red biohazard bags, contrary to facility policy. There was also a lack of proper supplies, such as red or dissolvable bags, in the designated areas for staff use. The facility also failed to ensure proper cleaning and disinfection of shared medical equipment. A licensed practical nurse was observed using a glucometer and blood pressure cuff on multiple residents without cleaning the devices between uses, despite being aware of the policy requiring disinfection with appropriate wipes. The nurse did not know the location of the sanitizing wipes and admitted to using personal equipment without cleaning it after each use. Additionally, mechanical lifts used for resident transfers were visibly soiled and not cleaned regularly, with staff acknowledging the lack of cleaning supplies and infrequent cleaning of the equipment.