Failure to Ensure PPE Use and Complete Infection Surveillance Documentation
Penalty
Summary
The facility failed to ensure that staff consistently used appropriate personal protective equipment (PPE) when providing care to a resident on Enhanced Barrier Precautions (EBP) and did not maintain complete infection control surveillance data. During the review of the infection control program for April 2023 to January 2024, it was found that monthly surveillance infection reports and analysis of infection trends were incomplete. The facility relied on monthly Antibiotic Reports for surveillance, but these reports lacked critical information such as whether infections were healthcare-associated or community-acquired, if McGeer's criteria were met, and details on new prophylactic treatments. Interviews with facility staff confirmed that the infection control surveillance reports were incomplete during this period, and it was the responsibility of the Infection Preventionist at the time to complete and analyze these reports. A resident with a history of neurocognitive disorder, Lewy bodies dementia, trigeminal neuralgia, and a sacral pressure ulcer was identified as requiring EBP due to a chronic wound. The care plan specified the use of gown and gloves during high-contact care activities. However, observations revealed that staff did not consistently follow these precautions. On multiple occasions, staff members provided wound care and incontinence care to the resident without donning the required PPE, such as gowns and masks, despite clear indicators (blue dots on name plaques) that the resident was on EBP. Staff interviews confirmed awareness of the EBP requirements, but they could not explain the failure to use PPE during care. Facility policy required maintaining separate infection records for each resident with an infection, analyzing clusters, and monitoring the infection control program quarterly or as indicated at quality improvement meetings. Despite these policies, the facility did not ensure complete documentation or consistent PPE use, as evidenced by direct observation and staff interviews. The lack of adherence to EBP protocols and incomplete infection surveillance documentation constituted the identified deficiencies.