Failure to Implement Infection Control Precautions and Proper PPE Availability
Penalty
Summary
The facility failed to notify a physician of a resident's urinalysis results that identified a multidrug-resistant organism (MDRO), providencia stuartii, and did not implement enhanced barrier precautions (EBP) or move the resident to a private room until several months after the diagnosis. The resident, who had diagnoses including cellulitis of the left lower limb and diabetes, remained in a semi-private room with another resident for over three months after the MDRO was identified. There was no documentation that the physician was notified of the urinalysis or that any orders for precautions were implemented until much later. The infection control map captured the urinalysis, but it was not included in the facility's infection control surveillance log. For another resident with cellulitis of the lower extremities, the facility failed to provide PPE or a container for PPE disposal despite orders for EBP. Observations confirmed that there was no PPE available inside or outside the resident's room, and staff interviews revealed a lack of awareness regarding responsibility for ensuring PPE availability. The resident's legs were red, swollen, and seeping fluid, and staff did not use gloves, gowns, or face shields when providing care, contrary to the care plan and physician orders. Additionally, the facility failed to properly store an ice scoop used for passing ice water, as it was found lying inside a portable cooler rather than in a designated holder. Staff interviews confirmed that this was not in accordance with infection control practices. The facility's policies required specific infection control measures for MDROs and EBP, including the availability of PPE and proper signage, but these were not consistently implemented or followed.