Failure to Implement Infection Control Precautions and Hand Hygiene
Penalty
Summary
The facility failed to implement and maintain effective infection prevention and control practices as evidenced by multiple observed deficiencies in the use of enhanced barrier precautions (EBP), contact precautions, and standard hand hygiene protocols. For two residents with indwelling medical devices, staff did not consistently use required personal protective equipment (PPE) such as gowns and gloves during high-contact care activities. In one case, a resident with a suprapubic catheter had EBP signage inside the room but lacked PPE availability in the room or bathroom, and there was no external indicator of EBP status. Staff admitted to forgetting to wear gowns and were unclear about the location and use of EBP indicators. Another resident with a feeding tube also did not have appropriate PPE available, and staff were unaware of the resident's EBP status despite signage being present in the room. For a resident being treated for a multidrug-resistant urinary tract infection, the facility did not follow contact precautions protocols. There was no signage on the door to indicate the type of precautions required, and PPE such as gloves, gowns, or masks was not readily available near the room entrance. Staff acknowledged the absence of proper signage and PPE setup, and there was confusion regarding the placement of EBP and contact precaution signage. Additionally, staff failed to perform required hand hygiene during incontinent care and meal tray delivery. During incontinent care, a CNA did not perform hand hygiene after removing gloves and before handling clean linen, only washing hands after disposing of soiled linens. During meal service, the same CNA did not perform hand hygiene between delivering trays to multiple residents, even after touching items in residents' rooms and assisting with feeding. Interviews with staff and review of facility policy confirmed that these actions were not in accordance with expected infection control practices.