Failure to Implement and Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, resulting in multiple lapses in infection control practices for six of eight residents reviewed. Several residents who were on contact or droplet precautions for communicable diseases such as Clostridium difficile, COVID-19, and metapneumovirus did not have the appropriate isolation precaution signage posted on their doors. In some cases, precaution signs were missing, posted late, or incorrectly identified the resident on precautions. Staff frequently entered and exited rooms of residents on isolation precautions without donning the required personal protective equipment (PPE) or performing proper hand hygiene. For example, staff were observed entering rooms without PPE, removing PPE outside of rooms, and failing to wash hands after glove removal. In one instance, a physical therapist wore PPE but left the resident's room to take phone calls without changing PPE, and a nurse entered a room with only a surgical mask when an N95 was required but unavailable in the PPE caddy. Laundry and housekeeping practices also failed to meet infection control standards. Contaminated laundry from residents on contact precautions was not consistently separated from general population laundry, and laundry staff were not always informed when items required special handling. Housekeeping staff did not consistently use PPE when handling refuse from isolation rooms and did not follow enhanced cleaning protocols, such as using bleach for rooms of residents with Clostridium difficile. Some staff reported cleaning all rooms the same way, regardless of isolation status, and using plain water for mopping instead of disinfectant. Additionally, staff responsible for laundry and housekeeping were not always aware of which residents were on precautions and did not consistently wear appropriate PPE due to discomfort or lack of communication. The facility's own policies required the use of color-coded precaution signs, proper PPE usage, and specific cleaning and laundry protocols for residents on isolation precautions. However, observations and staff interviews revealed widespread non-compliance with these policies. Staff were often unaware of the correct precautions, did not follow signage, and failed to implement required infection control measures, increasing the likelihood of transmission of communicable diseases among residents and staff.
Removal Plan
- The facility ensured all residents on precautions were reviewed and had the appropriate isolation precaution signage in place.
- All in-house staff were educated on infection control with competency-based training.
- All oncoming staff would be educated prior to the start of their shift.
- The facility provided in-service education to staff, with plans for ongoing education of staff not currently on the schedule, prior to the start of their next shift.