Failure to Implement Infection Control Program and Hand Hygiene Practices
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observed deficiencies. Enhanced Barrier Precautions (EBP) were not implemented for a resident with an indwelling urinary catheter upon their return from the hospital. Although the resident's care plan indicated the need for EBP, there was no EBP signage or PPE cart present near the resident's room for several weeks, and staff did not consistently use gowns during catheter care, only gloves. The Director of Nursing confirmed that EBP should have been in place earlier but was missed. Staff were also observed failing to perform appropriate hand hygiene after handling soiled items. A Certified Nursing Assistant (CNA) was seen transporting a soiled diaper, Hoyer sling, and resident's pants to the laundry receptacle without wearing gloves and did not perform hand hygiene after disposing of the items. The CNA then proceeded to assist residents in the dining room and touched common surfaces, such as a touch screen, without cleaning their hands. The CNA later acknowledged that hand hygiene should have been performed after handling soiled items and garbage receptacles. Additionally, residents were not offered hand hygiene prior to meals in the dining room. During a lunch observation, no sanitizing hand wipes were available on tables, and multiple residents were served meals without being offered hand hygiene. Interviews with residents and staff confirmed that hand hygiene was not routinely offered before meals, despite facility policy requiring it. The Director of Nursing and other staff acknowledged that residents should be provided with hand hygiene opportunities prior to eating.