Failure to Implement Effective Infection Control Practices
Penalty
Summary
The facility failed to implement and maintain effective infection prevention and control practices as evidenced by multiple observed deficiencies. One resident with a feeding tube and wounds was not placed on Enhanced Barrier Precautions (EBP) as required, despite having physician orders and being listed as needing EBP. The absence of an EBP sign on the resident's door meant that staff were not alerted to use appropriate personal protective equipment (PPE), such as gowns and gloves, during high-contact care, increasing the risk of transmission of multi-drug resistant organisms (MDROs). Staff interviews confirmed that EBP signage is necessary for residents with wounds or indwelling devices, and its absence could result in staff not following required precautions. Hand hygiene practices were also found to be deficient. A certified nursing assistant was observed passing food trays to multiple residents without performing hand hygiene between residents, even after touching her face and handling items on the dietary cart. There were no hand sanitizer dispensers available in the hallway, on PPE carts, or at the nurse's station, and staff reported that hand hygiene supplies were often insufficient or inconveniently located. Staff interviews revealed that the lack of accessible hand hygiene products made it challenging to comply with hand hygiene protocols, and sometimes staff had to purchase their own supplies. Additionally, the facility failed to properly handle soiled linen. Observations showed that soiled linens were sometimes thrown down the laundry chute without being bagged, and soiled linen bags could break open, leaving contaminated items exposed in the laundry area. Facility policy requires all soiled linen to be bagged and contained before being placed in the chute, but staff acknowledged that this was not always followed. These failures in infection control practices were observed to have the potential to affect all residents on the affected unit and throughout the facility.