Failure to Maintain Infection Control Practices and Equipment Integrity
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observed lapses during medication administration and equipment maintenance. Nursing staff were observed placing multi-dose medication containers and their packaging directly on resident surfaces, such as overbed tables and bedside tables, without using barriers. These items were then returned to the medication cart, creating a risk for cross-contamination. Staff also placed medication containers on the edge of sinks and on top of the medication cart without barriers. Interviews confirmed that staff understood the risk of transferring infectious agents but did not consistently use barriers, and the Director of Nursing acknowledged that while it was standard practice to use barriers, there was no written policy in place to support this practice. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for a resident with pressure ulcers, as required by facility policy. The resident did not have an order for EBP, nor was there signage on the door to indicate the need for these precautions. Furthermore, two residents were observed using wheelchairs with rips and tears in the plastic coverings, exposing the inner padding, which staff acknowledged could not be adequately cleaned to prevent infection. These findings demonstrate a lack of adherence to infection control protocols and failure to maintain equipment in a condition that supports infection prevention.