Infection Control Program Deficiencies and Lapses in Isolation and Hygiene Practices
Penalty
Summary
The facility failed to implement its infection prevention and control program as required, resulting in multiple lapses in infection control practices for both sampled and nonsampled residents. For one resident with a physician's order for contact isolation due to Clostridium Difficile colitis, the facility did not provide a private room, did not use dedicated medical equipment, and did not post appropriate signage indicating the required isolation precautions. Staff members, including an LVN and a CNA, did not follow proper PPE protocols or hand hygiene procedures, and the Infection Preventionist (IP) provided incomplete information to the resident's physician regarding the resident's ongoing symptoms, failing to review the medical record for continued episodes of diarrhea before discontinuing isolation. Additional deficiencies were observed in the handling of enhanced barrier precautions (EBP) for other residents. Signage indicating the type of isolation precautions was missing outside rooms where residents were on EBP for multidrug-resistant organisms, despite the presence of isolation carts and PPE instructions. Staff were observed transporting soiled linens against their clean scrubs without wearing gowns, contrary to facility policy, and failing to perform hand hygiene during and after medication administration, even after removing gloves or touching equipment in the vicinity of other residents. The facility also lacked a comprehensive, facility-specific water management program as required by CMS and its own policies. The water management binder did not contain the necessary flowcharts, testing protocols, or documentation of control measures and corrective actions. Staff interviews confirmed the absence of these required elements, and the facility was unable to provide evidence of a water management program that met regulatory and policy standards.