Failure to Track Infections, Identify Trends, and Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure comprehensive infection prevention and control practices were implemented and maintained. Specifically, the infection control tracking log for one unit in March 2025 did not include all infections that occurred, and the Infection Preventionist did not identify or act upon a trend of Methicillin-Resistant Staphylococcus Aureus (MRSA) infections. Three out of five infections on the unit involved MRSA, all of which were healthcare-associated, but the DON did not recognize this as a trend or provide staff education on hand hygiene, wound care, or contact isolation precautions, despite facility policy requiring tracking and trending of infections. Additionally, a resident with a urinary tract infection (UTI) was treated with antibiotics after a positive urine culture for proteus mirabilis, but this infection was not documented on the infection control log. The DON confirmed the omission during an interview, acknowledging that the infection should have been recorded according to facility procedures. Furthermore, another resident with open wounds on the buttocks did not have a care plan for enhanced barrier precautions, and staff did not follow CDC-recommended enhanced barrier precautions during wound care. Observation confirmed that gloves and gowns were not used during high-contact care activities, contrary to both facility policy and CDC guidance. These failures had the potential to affect all residents in the facility, which had a census of 84 at the time.