Failure to Implement and Maintain Infection Control Precautions
Penalty
Summary
The facility failed to implement and maintain appropriate infection prevention and control measures for multiple residents requiring Enhanced Barrier Precautions (EBP) and Contact Isolation. One resident with multiple wounds was not placed on EBP upon re-admission from the hospital, despite having an order for EBP and documented unstageable and stage 3 pressure injuries. The resident's room did not have the required EBP signage or personal protective equipment (PPE) available until it was noticed during a chart review, resulting in a delay in initiating necessary precautions. Another resident with a gastrostomy tube (G-tube) was not provided with EBP signage or PPE at the room entrance. Staff providing care to this resident did not consistently use the required gown and gloves during high-contact activities, such as medication administration via the G-tube and incontinence care. Additionally, a certified nursing assistant (CNA) failed to change soiled gloves before handling the resident's personal items and before continuing with clean care tasks, increasing the risk of cross-contamination. A resident on Contact Isolation for a Clostridium difficile infection had a private caregiver who was not informed of the isolation status and was not educated on the need to wear PPE while in the room. The caregiver provided direct care without wearing a gown or gloves until educated later in the day. Another instance involved a CNA providing incontinence care to a resident on supplemental oxygen, where the CNA failed to change soiled gloves before handling clean items and transferring the resident, contrary to facility policy and infection control standards.