Failure to Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in hand hygiene and use of personal protective equipment (PPE) during resident care. For one resident on enhanced barrier precautions (EBP) due to a urinary catheter, a CNA did not perform appropriate hand hygiene or don clean gloves while providing care, and an LPN did not wear a gown during high-contact care. Additionally, the resident's uncovered catheter drainage bag was observed on the floor, contrary to facility policy requiring catheter bags to be covered or shielded. During wound care for another resident with a right heel wound, an LPN failed to perform hand hygiene between glove changes while completing the dressing change procedure. The resident had severe cognitive impairment and required regular wound care as ordered in the medical record. The LPN acknowledged that hand hygiene should have been performed between glove changes, as confirmed by the Director of Nursing (DON). In a separate incident, a CNA providing perineal care to a resident with severe cognitive impairment and an open wound on the right lower leg removed soiled gloves and donned clean gloves without washing or sanitizing hands in between. The DON confirmed that hand hygiene should be completed between glove changes, especially after pericare. These observed failures to follow established infection control policies contributed to the deficiency cited by surveyors.