Failure to Maintain Infection Control Practices and Proper Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in infection control practices for several residents. For one resident with a diagnosis of ESBL, staff did not post required signage indicating contact precautions, failed to provide or use appropriate PPE, and did not perform hand hygiene after contact with potentially contaminated materials. The resident was observed outside her room for non-essential purposes, such as dining in a communal area, without staff or the resident using PPE, and without any risk assessment or clear policy guidance on when residents on contact precautions could leave their rooms. Visitors to the resident's room were not consistently informed or educated about PPE requirements, and staff interviews revealed confusion and lack of training regarding contact precautions and infection containment. During medication administration, staff failed to adhere to infection control protocols. A medication aide was observed handling oral medications with bare hands, failing to perform hand hygiene, and administering medication that had fallen onto the medication cart. These actions were contrary to facility policy, which requires hand hygiene and the disposal of contaminated medications. Interviews with staff confirmed that these practices were not in line with expectations and that proper procedures were not followed during the observed medication passes. Additionally, the facility did not ensure proper cleaning and disinfection of reusable medical equipment. After obtaining a blood glucose reading for a resident, a staff member failed to follow the manufacturer's instructions for disinfecting the glucometer, including not allowing the disinfectant to remain wet on the surface for the required time. The soiled glucometer was also placed on clean medical supplies without a barrier, risking cross-contamination. Staff interviews indicated uncertainty about the correct cleaning procedures and dwell times, and the facility's leadership confirmed that the observed practices did not meet policy or manufacturer requirements.