Failure to Maintain Effective Infection Prevention and Control Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by multiple lapses in environmental cleaning, use of personal protective equipment (PPE), and food handling practices. Observations revealed that an infusion pole used by a resident remained coated in a dried brown substance over several days, despite facility policies requiring routine cleaning and disinfection of medical equipment. Interviews with staff indicated confusion and inconsistency regarding responsibility for cleaning such equipment, with night shift CNAs, nursing staff, and Environmental Services each cited as responsible at different times. The Administrator was unaware that the IV pole required cleaning, indicating a lack of oversight and communication regarding infection control procedures. Further deficiencies were observed in the implementation of transmission-based precautions. A resident admitted with an open wound, colostomy, and chronic ulcer was placed on contact isolation due to a parasite, with physician orders and facility policy requiring staff to don full PPE before entering the room. However, a CNA entered the resident's room without PPE while delivering a meal tray, later admitting she was aware of the requirement but failed to comply due to time constraints. The DON, acting as the Infection Prevention Nurse, stated that agency staff were expected to be educated on precautions but did not verify completion of this training, and the Administrator was unable to articulate the potential negative outcomes of non-compliance. Additional infection control lapses were identified during meal service, where an LPN was observed handling unwrapped food items and straws with bare hands for several residents, contrary to facility policy. Both the LPN and DON acknowledged that gloves should have been worn and that direct contact with food and straws should be avoided. The Administrator confirmed the expectation for staff to use gloves and avoid contaminating food items, but these practices were not consistently followed, contributing to the overall deficiency in infection prevention and control.