Failure to Implement and Maintain Infection Prevention and Control Program
Penalty
Summary
Surveyors observed multiple failures in the implementation and maintenance of the facility's infection prevention and control program. Staff were seen not adhering to posted contact isolation precautions, including not donning personal protective equipment (PPE) such as gowns and gloves when entering rooms with contact isolation signage, and not performing hand hygiene before and after resident contact or between tasks. For example, an occupational therapist and several certified nursing assistants (CNAs) entered and exited rooms with contact isolation signage, assisted residents, delivered meal trays, and touched resident environments without using PPE or performing hand hygiene. Staff interviews revealed a lack of understanding regarding when PPE and hand hygiene were required, with some staff believing these precautions were only necessary during specific care activities, such as toileting, rather than for all resident contact or environmental interaction as indicated by facility policy and CDC guidelines. Additionally, the facility failed to ensure proper cleaning and sanitation of reusable resident drinking cups. Residents and staff reported inconsistent cleaning practices, with some cups being washed in resident room sinks or nourishment rooms using hand soap and water, and others sporadically sent to the kitchen for dish machine cleaning. There was no established or communicated schedule for cup sanitation, and staff were unclear about the process. The registered dietitian and director of nursing were not aware of the specific cleaning schedule, and staff provided conflicting information about cup handling and cleaning responsibilities. Further deficiencies were noted during medication administration. Nursing staff, including LPNs and RNs, were observed not performing hand hygiene before preparing or administering medications, and not changing gloves or using hand sanitizer as required by facility policy. In one instance, an RN dropped IV tubing on the floor, picked it up, and proceeded to use it without replacing it, contrary to facility expectations. Interviews with staff and the DON confirmed that these actions did not align with facility policy, which requires aseptic technique and hand hygiene during medication administration and when handling IV equipment.