Failure to Maintain Effective Infection Control Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program across all three units, the kitchen, and the main dining room. Observations revealed multiple lapses in hand hygiene practices, including staff not performing hand sanitization before and after resident contact, and residents not being provided hand hygiene before meals. Several wall-mounted hand sanitizer dispensers were found empty for extended periods, and staff did not consistently ensure their availability. Additionally, staff entered dietary areas without proper hair coverings or hand hygiene, and some staff admitted to forgetting these protocols due to being busy. Signage for Enhanced Barrier Precautions was missing outside rooms where it was required, and staff were observed providing care to residents on such precautions without wearing appropriate personal protective equipment (PPE). One resident with a suprapubic catheter, a condition requiring strict infection control, did not have the necessary signage posted, and the agency CNA providing care was not instructed on Enhanced Barrier Precautions. The Infection Control Nurse acknowledged gaps in the implementation of precaution signage and hand hygiene for residents receiving meals in their rooms. Interviews with staff, including the DON and Infection Control Nurse, revealed inconsistent understanding and application of infection control policies, particularly regarding when to use PPE and Enhanced Barrier Precautions. Plumbing issues led to shared bathrooms among residents and staff, further complicating infection control efforts. The Infection Control Nurse also stated that there were no infection control systems in place when assuming the role three months prior, and surveillance did not always catch missing signage or empty sanitizer dispensers.