Failure to Implement and Maintain Infection Control Measures
Penalty
Summary
The facility failed to maintain and implement proper infection control measures for multiple residents, as evidenced by the absence of required Enhanced Barrier Precautions (EBP) signage outside several rooms. Despite physician orders and care plans specifying the need for EBP due to conditions such as open wounds and colonization with multidrug-resistant organisms (MDROs), no EBP signage was posted outside the rooms of several residents. Instead, only droplet precaution signage was observed, which does not communicate the need for gowns and gloves as required by EBP. Interviews with the Infection Preventionist Nurse confirmed the importance of correct signage to prevent the spread of infection, and the lack of signage was acknowledged as a potential cause for the spread of infection. Staff also failed to don the required personal protective equipment (PPE) before entering rooms of residents on isolation or respiratory precautions. Certified Nursing Assistants (CNAs) entered the room of a resident on novel respiratory precautions for COVID-19 without wearing a respirator-type mask, face shield/goggles, or gown, as required by physician orders and care plans. In another instance, a CNA entered the room of a resident on droplet isolation precautions and assisted with meal setup without wearing a gown or gloves, despite posted signage and facility policy requiring such PPE. Staff interviews revealed a lack of awareness or attention to posted precaution signs, contributing to these lapses in infection control. Additional deficiencies included improper management of medical equipment and waste. A resident's suprapubic catheter drainage bag was observed touching the floor during multiple observations, contrary to facility policy and staff statements that the bag should be secured off the floor to prevent infection. Furthermore, sharps containers attached to medication carts were found to be overfilled beyond the manufacturer's fill line, posing an infection control risk. Staff interviews confirmed awareness of the risks associated with overfilled sharps containers and the need for timely replacement, as outlined in facility policy.