Failure to Implement and Document Infection Control Precautions and Surveillance
Penalty
Summary
The facility failed to implement and follow infection prevention and control policies and procedures, resulting in multiple deficiencies related to enhanced barrier precautions (EBP), transmission-based precautions (TBP), and process surveillance. On the first floor (100 unit), there was no evidence of EBP implementation for residents with conditions such as pressure ulcers, tube feeding, indwelling catheters, or tracheostomies, despite facility policy and CDC guidance requiring such measures. PPE was not readily available, and signage indicating EBP was absent. The policy and procedure for EBP lacked critical language from regulatory guidance, and staff, including the unit manager, were unaware of the requirements. The DON, acting as interim infection preventionist, acknowledged the lack of EBP implementation and inaccurate resident lists for precautions. A resident with a history of cerebral palsy, tracheostomy, gastrostomy tube, and colonization with Candida auris was placed on contact isolation upon admission, despite only being colonized and not actively infected. The care plan and physician's order indicated indefinite contact isolation, but there was no documentation supporting the need for such restrictive measures, nor was the use of least restrictive isolation considered. Staff were unclear about the appropriate use of EBP versus contact precautions, and the resident was not listed as having an active infection in the facility's records. The facility also failed to document and conduct process surveillance of infection control practices, as required by its own policies. The infection control risk assessment lacked supporting data and documentation of surveillance activities. Additionally, another resident admitted with C. difficile infection was placed on TBP, but appropriate signage was not posted on the door, and staff were unaware of the specific precautions required. The DON, acting as interim IP, confirmed the lack of signage and process surveillance documentation, and staff did not consistently follow TBP protocols.