Failure to Implement and Maintain Effective Infection Control Program
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program as required by policy and regulation. Specifically, several residents with wounds requiring dressing changes were not placed on Enhanced Barrier Precautions, and infection control practices were not consistently followed during wound care procedures. For example, residents with heel wounds did not have documented orders for Enhanced Barrier Precautions, despite their conditions necessitating such measures according to facility policy. During direct observation, an LPN performed a dressing change on a resident's heel wound without changing gloves after removing the soiled dressing, washed the wound from the outside in rather than inside out, and fanned the open wound with the clean dressing before application. These actions did not align with accepted infection control practices. The LPN was also unable to recall when they last received training on infection control and dressing changes, indicating a lapse in ongoing staff competency and education. Interviews with facility leadership revealed inconsistencies and uncertainty regarding the application of Enhanced Barrier Precautions versus Contact Precautions, particularly for residents with wounds, indwelling devices, or colonization with multidrug-resistant organisms. Leadership stated that precaution orders required physician authorization and acknowledged the need for further discussion and clarification of protocols upon the return of the Infection Preventionist. These findings demonstrate a lack of consistent implementation and oversight of infection control measures for residents at risk of infection.