Deficiencies in Infection Control Practices and Surveillance
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's infection prevention and control practices. During medication administration, an LPN was observed preparing and administering medications to two residents by dispensing tablets directly into their bare hands before placing them into medication cups. This practice was in direct violation of the facility's policy, which states that medications should not come into contact with any surface except the medication cup and that staff should avoid touching medications with bare hands. The Nursing Home Administrator confirmed that staff are required to follow this policy. Additionally, the facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with an unstageable pressure ulcer. Observations revealed that there was no signage on the resident's door indicating EBP, and during wound care, staff wore gloves but did not don a gown as required by the facility's EBP policy. The staff member performing wound care acknowledged uncertainty about the need for a gown due to the absence of signage, and the DON later confirmed that EBP should have been in place for this resident and that a gown should have been worn during wound care. The facility also failed to maintain an accurate infection surveillance data collection system. Review of the Antibiotic Use Tracking Log showed that no tracking was completed for a six-month period, from October 2024 through March 2025, despite the facility's policy requiring monthly documentation of antibiotic use and related infection data. The DON confirmed that the tracking log was not completed for those months.
Plan Of Correction
Preparation and submission of this plan of correction does not constitute an admission of, or agreement with, it is required by State and Federal Law. It is executed and implemented as a means to continuously improve the quality of care to comply with the state and federal requirements. 1. Residents 18 and 38 had an assessment completed, no ill effects were identified from the cited past deficient medication administration practice. Resident 44 had an assessment completed, no ill effects were identified from the cited past deficient practice regarding failure to follow enhanced barrier precautions. There were no residents affected by the cited past deficient practice related to incomplete Antibiotic Use Tracking Logs. 2. All residents have the potential to be affected by the cited past deficient medication administration practice. To identify others with the likelihood to be affected, the DON/designee completed a house-wide audit to ensure all residents that require enhanced barrier precautions have an order, signage, and an isolation caddy containing necessary PPE. Any missing necessary items will be immediately corrected. To identify others with the likelihood to be affected, the DON/designee completed an antibiotic order audit from the date of exit to present, ensuring that all new antibiotic orders are captured on the Antibiotic Use Tracking Log. The log will be updated with any orders that were inadvertently missed. 3. To prevent a future reoccurrence, the DON/designee will educate all licensed staff on the proper pouring of medications during med pass, ensuring medications do not come in contact with any other surface except the inside of the medication cup. To prevent a future reoccurrence, the DON/designee will educate all licensed nursing staff on the conditions that require enhanced barrier precautions, to ensure an order, signage, and an isolation caddy are present reflecting same. To prevent a future reoccurrence, the DON/designee will educate the Infection Preventionist on the proper completion of the Antibiotic Use Tracking Log. 4. To monitor and maintain ongoing compliance, the DON/designee will observe 3 random licensed nurses administering medications to one resident, ensuring medications poured during med pass do not come in contact with any other surface except the inside of the medication cup. Any deficient practice identified will be immediately corrected. This will occur weekly for 4 weeks and then monthly for 2 months. To monitor and maintain ongoing compliance, the DON/designee will audit 5 random residents requiring enhanced barrier precautions, ensuring an order, signage, and isolation caddy are present. Any missing items will be immediately corrected. This will occur weekly for 4 weeks and then monthly for 2 months. To prevent a future reoccurrence, the DON/designee will educate the Infection Preventionist on the proper completion of the Antibiotic Use Tracking Log. To monitor and maintain ongoing compliance, the DON/designee will complete an audit of 3 random antibiotics ordered, ensuring the necessary information is present on the Antibiotic Use Tracking Log for the initiation of the antibiotic. Any missing information will be immediately corrected weekly for 4 weeks, and then monthly for 2 months. All findings will be reported to the QA committee monthly for any further necessary recommendations.