Failure to Implement and Maintain Infection Control Practices and Proper PPE Use
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices within the facility, particularly regarding hand hygiene, personal protective equipment (PPE) use, and the storage and maintenance of wound care supplies. Staff members, including LPNs and homemakers, were observed entering and exiting the rooms of residents on contact precautions or enhanced barrier precautions (EBP) without performing hand hygiene or donning required PPE such as gowns and gloves. PPE supplies were not consistently available outside or inside the rooms of residents requiring precautions, and signage for contact precautions was missing for a resident with an active wound infection and a history of MRSA. Staff were also observed performing direct care and environmental tasks without appropriate PPE, and some were unaware of the specific requirements for residents on EBP or contact precautions. A resident with chronic kidney disease, a recent dialysis fistula, a central line, and a history of chronic empyema with an unhealed, infected chest wound was not placed on contact precautions as ordered by the physician. The resident had a history of MRSA and was receiving antibiotics for a surgical wound infection, yet staff did not consistently follow the required infection control measures. Observations revealed that wound care supplies were not stored in resident rooms but were instead kept in shared treatment carts or storage rooms, with supplies for different residents sometimes stored together in non-cleanable cardboard bins. Multi-use items such as scissors were visibly soiled, and expired or unlabeled wound care supplies were found in the treatment cart. Interviews with staff, including the DON and infection preventionist, revealed confusion and inconsistency regarding the storage and availability of PPE, as well as the implementation of EBP and contact precautions. Staff were unclear about the specific precautions required for residents with chronic wounds or MDROs, and there was a lack of clear communication and documentation regarding physician orders for infection control measures. The facility's policies required proper storage, labeling, and dating of supplies, as well as adherence to PPE protocols, but these were not consistently followed, leading to the identified deficiencies.