Failure to Maintain Effective Infection Prevention and Control Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in following established protocols during a gastrointestinal (GI) illness outbreak and in the management of multidrug-resistant organisms (MDROs). The outbreak line lists for both staff and residents were incomplete, lacking critical information such as the date and time of last symptoms, which is necessary to determine the appropriate duration for contact precautions and staff exclusion from work. As a result, two residents were removed from contact precautions prematurely, contrary to facility policy, and the County Health Department was not updated on new cases as required. Additionally, discrepancies existed between the staff illness line list and the human resources call-in list, further complicating outbreak management. Staff did not consistently adhere to infection control protocols related to enhanced barrier precautions (EBP) and contact precautions. For example, an LPN failed to wear a gown while manipulating a resident's clothing to administer a pain patch, despite the resident being on EBP for MDRO colonization. Staff also entered a resident's room on contact precautions without donning personal protective equipment (PPE), and soiled linens were transported through hallways without being properly bagged, increasing the risk of cross-contamination. Furthermore, staff did not sanitize shared equipment, such as a mechanical lift, after use with a resident on EBP, and hand hygiene was not offered to residents before or after meals during an active Norovirus outbreak. Observations and interviews revealed a lack of understanding and inconsistent application of infection control policies among staff, including the handling of soiled linens, use of PPE, and adherence to hand hygiene protocols. Residents with cognitive impairments and those responsible for their own healthcare decisions were affected by these lapses. The facility's own policies, which align with state and federal regulations and national guidelines, were not followed, resulting in practices that had the potential to affect all residents in the facility.