Failure to Implement Effective Infection Control and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program, as evidenced by multiple deficiencies in infection surveillance, antibiotic stewardship, and adherence to enhanced barrier precautions (EBP). For one resident with a stage 3 sacral pressure ulcer and an open surgical wound, staff did not follow EBP protocols during wound care. Specifically, gowns and gloves were not available near or outside the resident's room, there was no signage indicating EBP was in place, and staff, including an LPN and two CNAs, did not don protective gowns while performing and assisting with wound care. The facility's regional nurse consultant confirmed that EBP should have been in place for this resident due to the presence of open wounds. Additionally, the facility did not maintain complete and accurate infection surveillance records. The Monthly Infection Logs were not completed for several consecutive months, and the Antimicrobial Days of Therapy Reports lacked critical information such as infection site, pathogen, signs and symptoms, resident location, diagnostic reports, and analysis. Several residents who received antibiotics for urinary tract infections were not included in the UTI log, and the infection preventionist acknowledged that while McGeer criteria were reviewed, this was not documented. The facility also failed to follow manufacturer guidelines for disinfecting blood glucose monitors. After performing blood glucose monitoring on a resident, an LPN cleaned the meter with an alcohol wipe instead of the required disinfectant wipe, and the device was returned to the medication cart. The DON confirmed that the correct disinfectant wipes should have been used. This practice potentially affected multiple residents who required blood glucose monitoring from the same medication cart.