Failure to Implement Infection Prevention and Control Measures
Penalty
Summary
The facility failed to implement multiple infection prevention and control measures as required by policy and regulatory guidance. Staff did not use Enhanced Barrier Precautions (EBP) for residents with indwelling devices such as gastrostomy tubes, as observed with several residents. In multiple instances, there was no EBP signage posted, no isolation carts available, and staff were unaware of EBP protocols. Interviews revealed that staff had not received in-service training on EBP, and the Infection Preventionist Nurse (IPN) confirmed that education and signage had not been provided. Additionally, staff were observed providing direct care to residents with G-tubes without donning appropriate personal protective equipment (PPE) such as gowns and gloves, contrary to facility policy and CDC guidance. The facility also failed to implement its water management plan, which is designed to prevent waterborne illnesses. The Maintenance Director stated that there were no logs or records indicating that water quality was being monitored as required, and the administrator confirmed that the water management program had not been implemented. This was in direct contradiction to the facility's own water management and Legionella prevention plan, which called for regular testing and documentation. Further deficiencies were observed in basic infection control practices, including hand hygiene and laundry handling. A certified nurse assistant was seen moving between residents without performing hand hygiene or properly disposing of gloves, and maintenance/laundry staff handled clean linens in a manner that allowed them to touch the floor and their clothing, did not use PPE when handling soiled laundry, and placed personal items near clean linens. Additionally, the facility failed to implement appropriate contact isolation precautions for a resident being treated for scabies, as only the affected resident was placed under isolation rather than the entire shared room, and there was no comprehensive assessment or prophylactic treatment for contacts as recommended by local guidelines.