Failure to Implement and Communicate Infection Control Precautions
Penalty
Summary
The facility failed to implement and follow infection prevention and control procedures for multiple residents requiring isolation or enhanced barrier precautions (EBP). For one resident with a Stage 3 pressure injury, there was no EBP signage or isolation cart with personal protective equipment (PPE) outside the room, despite physician orders and care plan interventions requiring these measures. The Infection Prevention Nurse confirmed that signage and PPE carts should have been present to ensure staff compliance with EBP protocols. Another resident with a gastrostomy tube and severely impaired cognition was observed receiving medication administration from an LVN who did not don a gown, as required under EBP. The LVN acknowledged the omission and stated that a gown should have been worn to prevent cross-contamination. Additionally, a resident with a biliary drain and central line did not have EBP signage posted outside the room, despite orders and facility policy indicating that such signage is necessary to communicate required precautions to staff and visitors. Further deficiencies included a disposable gown left hanging on the doorknob inside the room of a resident on contact isolation for a multidrug-resistant organism (MDRO), contrary to facility policy that requires immediate disposal of used gowns. The facility also lacked a water management program with a diagram or text assessing where Legionella or other waterborne pathogens could grow, as required by their own policy. These failures were confirmed through staff interviews and review of facility policies and procedures.