Infection Control Program Deficiencies and Hand Hygiene Failures
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by incomplete infection surveillance and improper hand hygiene practices. Infection surveillance logs were missing critical data, such as the type and location of outbreaks, testing performed, well dates for residents and staff, and details regarding isolation precautions. During an influenza outbreak, the facility did not document essential information needed to monitor and prevent the spread of infection. The Nursing Home Administrator acknowledged that the facility relied on a county-provided spreadsheet and was unaware that additional data was required for adequate infection monitoring. Staff infection tracking was also inconsistent, as staff did not always complete required screening forms. Direct care observations revealed multiple instances of improper hand hygiene and infection control breaches. An LPN was observed handling medications with bare hands, failing to sanitize hands before touching pills, and returning a dropped pill from a contaminated surface to a resident's medication cup. The LPN admitted awareness of proper procedures but did not follow them due to concerns about medication costs. Additionally, a CNA was observed performing resident care without completing hand hygiene before donning gloves, after removing gloves, or between tasks, and used contaminated gloves to touch clean surfaces and equipment. The CNA claimed to use hand gel frequently, but surveyors did not observe any hand hygiene during care. Residents with complex medical needs, such as those with indwelling catheters, were also affected by these lapses. One resident with a suprapubic catheter and nephrostomy tube received care from staff who failed to change gloves or perform hand hygiene when moving between clean and dirty areas during catheter care and dressing changes. During a catheter change, an LPN switched from sterile to non-sterile gloves without hand hygiene and manipulated the catheter, later acknowledging the omission. These failures in infection control practices had the potential to affect all residents in the facility.