Failure to Implement Infection Prevention and Control Policies
Penalty
Summary
The facility failed to implement its infection prevention and control policies and procedures for five sampled residents, resulting in multiple deficiencies. For one resident with dementia and osteoarthritis, the urinal was found hanging on a garbage can, unlabeled and filled with urine, rather than being labeled and stored in a designated basket as required. Staff interviews confirmed that urinals should be labeled with the resident's name or room number and stored properly to prevent cross-contamination, but this was not done in this instance. Another resident with end stage renal disease and a dialysis catheter, who was on Enhanced Barrier Precautions (EBP), did not have staff wearing the required personal protective equipment (PPE) during high-contact care activities such as range of motion exercises. The staff member acknowledged that gowns and gloves should have been worn to prevent cross-contamination, and facility policy confirmed this requirement for residents with indwelling medical devices or a history of multidrug-resistant organisms (MDROs). Additionally, a staff member failed to change PPE between providing care to two different residents, both of whom were on EBP due to wounds or indwelling devices. The staff member wore the same gown and gloves while assisting both residents with personal care and did not perform hand hygiene or don new PPE between residents, contrary to facility policy and staff training. In another case, a resident with bilateral nephrostomy tubes did not have EBP signage or a PPE cart outside the room, and staff were unaware of the need for EBP, resulting in care being provided without the required gown and gloves. These failures were observed and confirmed through staff interviews and review of facility policies.