Failure to Follow Infection Control Protocols and Maintain Precaution Signage
Penalty
Summary
The facility failed to follow established infection prevention and control protocols in several key areas, as observed through direct staff actions and environmental conditions. Staff did not consistently perform hand hygiene between resident contacts during meal service. For example, an activity aide and a CNA were observed setting up food trays and assisting residents without sanitizing their hands between tasks, despite facility policy and staff acknowledgment that hand hygiene is required after contact with residents or their wheelchairs. This lapse was noted during meal service for multiple residents with severe cognitive impairment and complex medical conditions, such as hemiplegia, epilepsy, and malnutrition. The facility also failed to properly implement and display Enhanced Barrier Precaution (EBP) signage and provide necessary personal protective equipment (PPE) for residents requiring these precautions. Several residents with wounds, surgical incisions, or indwelling medical devices did not have EBP signs posted on their doors, and PPE bins were not always available as required. In some cases, EBP orders were delayed or not in place upon admission, and signage was missing or removed without immediate replacement. Staff interviews confirmed that the expectation is for clear signage and PPE availability to inform staff of required precautions, but these measures were not consistently followed. Additionally, the facility did not maintain sanitary conditions in the laundry area. Clean linens and personal laundry were observed on the floor, and staff acknowledged that this practice is not permitted due to the risk of cross-contamination. Facility policies require that all linens and personal laundry be handled, stored, and transported in a manner that prevents the spread of infection, but these procedures were not adhered to during the survey. These failures affected multiple residents with complex medical needs and placed all residents at risk for the spread of infection.