Deficient Infection Prevention and Control Program and Lapses in Medication Administration
Penalty
Summary
The facility failed to implement an effective Infection Prevention and Control Program (IPCP), as evidenced by multiple deficiencies in documentation, surveillance, and infection control practices. The facility's water management plan (WMP) was outdated, listing previous staff as responsible team members and lacking current verification of control measures. The Infection Preventionist (IP) was not included in the WMP team, and the current Director of Nursing (DON), who was serving as the IP, had not completed infection control training. The Director of Maintenance reported conducting weekly water testing and maintenance activities but did not retain documentation of these actions, including chlorine testing and water temperatures. Infection surveillance reports for several months were incomplete, lacking definitions for infections, identification of infectious organisms, and documentation of corrective actions taken in response to identified infections. The reports listed various infections, such as skin conditions, urinary tract infections, pneumonia, and eye infections, but did not provide sufficient detail or evidence of follow-up. Interviews with facility leadership revealed a lack of awareness regarding the deficiencies in the surveillance program and the absence of supporting documentation for infection control activities. Additionally, infection control practices during medication administration were not followed. The DON was observed administering eye drops to a resident without donning gloves, contrary to the facility's protocol, which requires hand hygiene, glove use, and subsequent hand hygiene. The DON confirmed knowledge of the correct procedure during an interview but failed to implement it during the observed medication pass. These deficiencies had the potential to affect all residents in the facility.