Failure to Monitor Infections and Ensure Hand Hygiene
Penalty
Summary
The facility failed to properly monitor and log infections, as well as identify possible infection trends, as evidenced by the omission of a resident's sepsis and urinary tract infection (UTI) from the Infection Control Log. Medical record review showed that a resident with multiple diagnoses, including respiratory failure and heart failure, was admitted and later diagnosed and treated for sepsis and UTI in the hospital. However, the infection preventionist confirmed that these infections were not recorded in the facility's infection control log, and no trends or patterns were identified, despite multiple residents being diagnosed with UTIs caused by E. coli. Additionally, the facility failed to ensure proper hand hygiene practices during incontinence care. Observation revealed that a certified nurse assistant (CNA) provided incontinence care to a resident, disposed of soiled materials, and changed gloves without performing hand hygiene before or after glove changes, contrary to facility policy. The CNA also handled personal items and applied ChapStick to the resident without washing hands. Policy review confirmed that hand hygiene is required after glove removal and after contact with body fluids or contaminated surfaces, but these procedures were not followed during the observed care.