Failure to Implement and Enforce Infection Control Precautions
Penalty
Summary
The facility failed to implement and enforce appropriate infection prevention and control measures for multiple residents requiring transmission-based and enhanced barrier precautions. In one instance, a physician assessed a resident with ongoing diarrhea and pending C. difficile test results without donning any personal protective equipment (PPE), and there was no transmission-based precautions signage posted on the resident's door. The resident confirmed that she was not placed on precautions despite her symptoms, and her care plan later indicated strict contact isolation after a positive C. difficile result. The Director of Nursing acknowledged that the resident should have been placed on contact precautions immediately upon identification of GI symptoms. In another case, a certified nurse assistant entered a resident's room, which had a contact precautions sign due to a VRE wound, without wearing the required gown and gloves. The CNA stated she did not believe adherence to the posted precautions was necessary. Additional deficiencies were observed with residents on enhanced barrier precautions (EBP) due to indwelling medical devices. Staff members, including CNAs and LPNs, provided high-contact care activities such as perineal care, repositioning, and gastrostomy tube checks while wearing gloves but not gowns, and failed to perform hand hygiene or change gloves between tasks. Soiled linens were also removed from rooms without proper containment or hand hygiene. Further, a resident with a history of VRE and orders for EBP did not have any isolation signage or PPE bin near her room. Staff provided incontinence care without wearing gowns and failed to perform hand hygiene after glove removal. Facility policies required the use of gowns and gloves during high-contact care for residents on EBP and specified hand hygiene protocols, but these were not consistently followed by staff, as confirmed by staff interviews and record reviews.