Infection Control Program and Enhanced Barrier Precautions Deficiencies
Penalty
Summary
The facility failed to maintain a comprehensive infection prevention and control program as required by federal regulations. The Infection Control Preventionist (ICP) had not compiled infection control data for several months, including April and May, and there was no documentation of monthly summaries, infection rates, lists of facility infections, mapping for trends or outbreaks, line listings for antibiotic usage, pharmacy or laboratory reports, departmental surveillance, or staff education for October, November, or December of the previous year. For January, February, and March, only partial data was available, and the line listings did not demonstrate that prescribed antibiotics met McGeer's Criteria. The Director of Nursing acknowledged that the infection control program had not been comprehensively maintained by the previous ICP. Additionally, the facility failed to ensure proper identification and implementation of enhanced barrier precautions (EBP) for residents with indwelling medical devices or wounds. Multiple residents with PICC lines or urinary catheters did not have appropriate EBP signage outside their rooms, and in some cases, EBP orders were missing or delayed in the clinical records. Observations revealed that signage, when present, did not specify which resident in shared rooms was on EBP, leading to confusion and lack of clarity for staff and visitors. Some residents with qualifying conditions for EBP had no signage at all, while others had signage that did not accurately reflect their status. Facility policy required that residents with wounds or indwelling medical devices be placed on EBP upon admission, with physician orders and clear signage indicating the specific resident on precautions. However, the observed practices did not align with these policies, as evidenced by missing or unclear signage, delayed or absent orders, and inconsistent application of EBP. These deficiencies were confirmed through interviews with the ICP and review of facility policies and resident records.
Plan Of Correction
F 880 Infection Control Deficient Practice #1 ELEMENT #1: Infection control program data for April & May 2025 was completed. ELEMENT #2: Current residents have the potential to be affected by the deficient practice. An infection control program that includes preventing, identifying, reporting, investigating, and monitoring and surveillance infections was put into place for June 2025. ELEMENT #3: The policy, "Infection Control Surveillance," was reviewed and deemed appropriate. The policy remains in place. The Infection Preventionist was re-educated on the policy, "Infection Control Surveillance," with emphasis on data collection and tracking. ELEMENT #4: The Director of Nursing and/or designee will conduct random audits of 5 residents with identified and/or potential infections to ensure substantial compliance with infection control data tracking. Audits will be conducted weekly for four weeks then monthly for two months. Any concerns will be immediately addressed. The results of the audits will be reviewed by the QAPI committee monthly for 3 months for further recommendations. Any area of non-compliance will be addressed. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025 --- F 880 Infection Control Deficient Practice #2 ELEMENT #1: Enhanced Barrier Precautions were put into place for residents #126, 233, 235, 4, 234, 85, and 30. ELEMENT #2: Current residents requiring Enhanced Barrier Precautions have the potential to be affected by the deficient practice. Current residents requiring Enhanced Barrier Precautions were evaluated to ensure Enhanced Barrier Precaution signage was in place and orders were entered into the electronic medical record. Any resident identified as needing Enhanced Barrier Precautions had proper signage placed and orders entered into the electronic medical record. ELEMENT #3: The policy, "Enhanced Barrier Precautions," was reviewed and deemed appropriate. The policy remains in place. Licensed Practical Nurses and Registered Nurses were re-educated on the policy, "Enhanced Barrier Precautions," with emphasis on proper signage and orders. ELEMENT #4: The Director of Nursing and/or designee will conduct random audits of 5 residents needing enhanced barrier precautions (EBP) to ensure substantial compliance with enhanced barrier precautions, including signage and MD orders. Audits will be conducted weekly for four weeks then monthly for two months. Any concerns will be immediately addressed. The results of the audits will be reviewed by the QAPI committee monthly for 3 months for further recommendations. Any area of non-compliance will be addressed. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025