Widespread Infection Control Failures and Documentation Lapses
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies in surveillance, documentation, and implementation of infection control practices. There were discrepancies in the facility’s infection surveillance logs and line listings, with missing documentation for several months and inaccurate reporting of residents who received antibiotics and those with multidrug-resistant organism (MDRO) infections. The Infection Control Committee minutes did not accurately reflect the number of residents affected, and there was no documented evidence of recommendations or follow-up actions to address the high incidence of E. coli and proteus mirabilis infections. Additionally, the committee failed to discuss the antibiogram and its correlation with urinary tract infections (UTIs) or to document protocols to address the MDRO infection rate. Observations revealed lapses in infection control practices, including the absence of Enhanced Barrier Precaution (EBP) signage and personal protective equipment (PPE) outside a resident’s room, and staff not wearing gowns during high-contact care activities such as wound and catheter care. Clean linens were improperly handled and stored, with staff placing them on used surfaces without protective covering. Shared resident-care equipment, such as basins and bedpans, were found unlabeled and improperly cleaned or stored in shared restrooms, and a urinal was found unlabeled on a bedside table. In another instance, a resident’s urinary catheter tubing was observed lying on the floor, contrary to facility policy. Further deficiencies included staff not donning appropriate PPE when entering a contact isolation room, as required by posted signage and facility policy. There were also environmental cleanliness issues, such as brown stains on the floor and wall in a resident’s room on contact precautions, and soiled items found on the floor of a medication room. In one case, a staff member attempted to reapply a used diaper with visible drainage to a resident after catheter care, rather than using a clean diaper. These failures were verified through interviews with staff, including the Infection Preventionist, DON, and other facility personnel, who acknowledged the findings.