Failure to Implement and Enforce Infection Control Measures
Penalty
Summary
The facility failed to implement and maintain proper infection prevention and control measures for residents requiring enhanced barrier precautions. In two cases, residents with conditions necessitating enhanced barrier precautions—one with a Stage III pressure sore and another with a Foley catheter—did not have the required signage posted outside their rooms. There was also no evidence of a PPE supply cart or staff donning extra PPE for the resident with the pressure sore. Staff interviews confirmed awareness that these conditions required enhanced barrier precautions, but the signage and procedures were not consistently followed or implemented. Additionally, a staff member with a persistent cough, reportedly following a recent influenza outbreak, was observed not wearing a mask while coughing in a communal dining area. Multiple staff interviews indicated that this staff member was repeatedly reminded to wear a mask, in accordance with posted facility signage and policy, but did not consistently comply. The facility's posted instructions clearly stated that anyone with illness symptoms should wear a mask, but this was not enforced. Furthermore, a staff member working in the laundry area failed to perform hand hygiene after removing contaminated gown and gloves before entering the clean side of the laundry facility. This was observed by another staff member, who acknowledged the lapse and intended to address it. Facility policies required hand hygiene after handling contaminated laundry, but this protocol was not followed in practice.