Failure to Maintain Effective Infection Prevention and Control Program
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple direct observations of staff not adhering to established infection control practices. Staff were observed failing to perform hand hygiene, not wearing appropriate personal protective equipment (PPE) during high-contact care, and improperly handling contaminated linens and trash. For example, a certified nurse aide provided direct care to a resident under enhanced barrier precautions without donning a gown, and several staff members were seen transporting dirty linens and trash through hallways without removing gloves or performing hand hygiene. Additionally, clean and contaminated items were improperly stored, such as respiratory equipment and dentures left to dry on a stained towel in a resident's bathroom, and clean privacy curtains dragged on the floor before being hung. Shared equipment, including gait belts, blood glucose meters, blood pressure cuffs, and mechanical lifts, was not consistently cleaned and disinfected between resident use. An LPN was observed performing a blood sugar fingerstick without following infection control protocols, including failing to clean and disinfect the glucometer according to manufacturer instructions and not performing hand hygiene before or after the procedure. Other staff members admitted to not cleaning equipment between uses unless a resident was on contact precautions, and there was confusion or lack of knowledge regarding proper disinfection procedures and required contact times for cleaning products. Environmental cleanliness and waste management were also deficient. Trash and contaminated linens were left on floors in resident rooms and hallways, and infectious waste was observed scattered around the dumpster area outside the facility. Staff interviews revealed inconsistent understanding and application of infection control policies, despite reported training and competencies. These failures were observed to affect multiple residents, including those with severe cognitive impairment, indwelling devices, and those under enhanced barrier precautions, and had the potential to impact all residents in the facility.