Infection Control Program Deficiencies and Lapses in Staff Practice
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by several deficiencies in policy, staff practice, and environmental management. The written policies and procedures for the infection prevention and control program did not include a list of communicable diseases, nor did they specify when and to whom incidents of communicable diseases or infections should be reported. Additionally, the policies regarding COVID-19 infection prevention and control were outdated. Staff interviews revealed a lack of awareness and training regarding communicable diseases, with multiple staff members unable to locate or identify the relevant policies or the list of communicable diseases. The infection preventionist acknowledged the absence of required information in the policy binder and the need for updates. A certified nursing assistant failed to wear appropriate personal protective equipment (PPE) when providing care to a resident on enhanced barrier precautions for a chronic leg ulcer. The CNA admitted to not wearing PPE, and both the infection preventionist and the director of nursing confirmed that PPE was required for such care to prevent cross contamination. Observations and interviews confirmed that staff were aware of the need for PPE but did not consistently follow protocols, increasing the risk of infection transmission. A licensed vocational nurse used the same pair of gloves to administer oral medication, injectable insulin, and eye drops to a resident, without changing gloves or performing hand hygiene between different routes of medication administration. The nurse acknowledged this practice and recognized it as incorrect. The infection preventionist and director of nursing both stated that gloves should be changed between different medication routes to prevent cross contamination. Additionally, a resident's urinal was observed hanging in a trash can with the handle touching the trash, a practice that both staff and the infection preventionist identified as a risk for cross contamination and infection. The resident preferred this arrangement for accessibility, but staff recognized it did not meet infection control standards.