Widespread Infection Control Failures and Lapses in Staff Practice
Penalty
Summary
The facility failed to maintain its infection prevention and control program as required, resulting in multiple deficiencies. The Infection Preventionist (IP) did not conduct infection control monitoring and surveillance for April 2025, including failing to review residents' antibiotic orders to determine if they met Loeb's or McGeer's Criteria for infection. This oversight led to antibiotics being administered without proper justification, as evidenced by a resident receiving antibiotics without meeting the necessary criteria. Additionally, the facility did not adhere to its Legionella Water Management Program, performing Legionella testing annually instead of the required quarterly frequency. Several lapses in infection control practices were observed among staff. One resident on contact enteric precautions for C. diff did not have proper hand hygiene protocols followed by visiting healthcare providers, who were misinformed about the type of isolation required. Staff were also observed storing personal cell phones in treatment carts, placing face shields on contaminated surfaces, and failing to don appropriate personal protective equipment (PPE) during high-contact care for residents on enhanced barrier precautions. Clean linen was transported in an uncovered cart, allowing it to come into contact with potentially contaminated surfaces. Medication administration practices were also deficient. Two LVNs did not follow proper hand hygiene procedures during medication passes, and the tip of an eye dropper touched a resident's eyelashes during administration, violating infection control policy. Additionally, a glucometer was found with red-brown smudges, indicating inadequate cleaning. These failures collectively posed a risk for the transmission of communicable diseases and infections within the facility.