Infection Control Program Deficiencies: PPE, Isolation, and Hand Hygiene Failures
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by multiple observed deficiencies in the use of personal protective equipment (PPE), posting and adherence to isolation precautions, and hand hygiene practices. Staff were observed entering rooms requiring special contact/droplet precautions without donning appropriate PPE, and residents on such precautions were seen moving freely in hallways without masks. Interviews with staff revealed inconsistent understanding of when PPE was required, with some staff only wearing PPE during direct care and others unsure of the correct precautions. In several instances, isolation signage was missing from doors of rooms with residents positive for COVID-19, and staff were unaware of the necessary precautions until prompted by surveyors. Hand hygiene practices were also not consistently followed. Staff were observed administering injections, handling medication carts, and performing blood glucose checks without performing hand hygiene between tasks or between resident contacts. Shared medical equipment, such as blood pressure cuffs and glucose monitoring strip bottles, were not cleaned between uses or after being in resident rooms, and respiratory masks were left uncovered in resident rooms. Staff interviews confirmed that proper hand hygiene and equipment cleaning protocols were not always followed, and the DON acknowledged that these practices were not in line with facility policy. Additional deficiencies included improper management of indwelling urinary catheters, with a resident's catheter bag observed clipped to a garbage can and touching the floor, contrary to physician orders and care plan interventions. Staff were also observed with artificial nails, which is against facility policy for direct care staff. Housekeeping staff demonstrated inconsistent understanding of PPE requirements for different types of precautions, and language barriers further complicated adherence to protocols. Review of care plans and policies confirmed that the observed practices did not align with established infection control procedures.