Failure to Implement Infection Control Measures and Precautions
Penalty
Summary
The facility failed to implement and maintain infection control measures for multiple residents, specifically by not applying Enhanced Barrier Precautions (EBP) for twelve residents who met the criteria due to the presence of indwelling medical devices such as gastrostomy tubes, open wounds, or multidrug-resistant organisms (MDROs). Observations revealed that there was no signage or personal protective equipment (PPE) available outside the rooms of these residents, and the Infection Preventionist (IP) confirmed that EBP was not being used for any residents, despite facility policy requiring it for those with certain risk factors. Documentation reviews for each affected resident confirmed the presence of conditions necessitating EBP, yet the required precautions were not in place. The facility also failed to maintain and implement a water management system designed to reduce the risk of Legionella and other opportunistic pathogens. The Maintenance Supervisor was unable to provide records of the water management plan or documentation describing the facility's water system, and the IP had not participated in any water management activities, despite being listed as a team member in the facility's policy. The policy required regular verification of the system's implementation and annual evaluation of its effectiveness, but there was no evidence these activities had occurred. Additional infection control lapses were observed, including an incident where a resident with moderate cognitive impairment ate food from another resident's partially consumed tray left on a hallway food cart. Staff interviews confirmed that residents should be monitored to prevent such occurrences, but monitoring was not consistently in place. Furthermore, a Treatment Nurse did not perform hand hygiene between glove changes while providing wound care to a resident with a Stage 4 pressure ulcer, contrary to facility policy and best practices. The nurse acknowledged the lapse and its potential to introduce bacteria during wound care.